Debating Your Plate: The Most Controversial Foods and Ingredients 9781440874352, 9781440874369, 1440874352

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Debating Your Plate

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Debating Your Plate The Most Controversial Foods and Ingredients Randi Minetor

Copyright © 2022 by ABC-CLIO, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher. Library of Congress Cataloging-in-Publication Data Names: Minetor, Randi, author. Title: Debating your plate : the most controversial foods and ingredients / Randi Minetor. Description: 1st edition. | Santa Barbara, California : Greenwood, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2021009692 (print) | LCCN 2021009693 (ebook) | ISBN 9781440874352 (hardcover) | ISBN 9781440874369 (ebook) Subjects: LCSH: Nutrition. | Food preferences. | Diet. | Food habits. Classification: LCC RA784 .M51512 2022 (print) | LCC RA784 (ebook) | DDC 613.2—dc23 LC record available at https://lccn.loc.gov/2021009692 LC ebook record available at https://lccn.loc.gov/2021009693 ISBN: 978-1-4408-7435-2 (print) 978-1-4408-7436-9 (ebook) 26 25 24 23 22  1 2 3 4 5 This book is also available as an eBook. Greenwood An Imprint of ABC-CLIO, LLC ABC-CLIO, LLC 147 Castilian Drive Santa Barbara, California 93117 www.abc-clio.com This book is printed on acid-free paper Manufactured in the United States of America

Contents Introduction1 Why Is Nutrition So Controversial?

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The History of Food Controversies

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How to Evaluate Nutrition Research and Health Claims

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Foods and Ingredients

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Artificial Flavorings 31 Artificial Food Colors 37 Artificial Sweeteners 42 Bottled Water 48 Caffeine54 Carbonated Beverages 61 Carrageenan65 Chocolate70 Coconut Oil 78 Cruciferous Vegetables 84 Dairy Products 90 Eggs98 Essential Oils 103 Farm-Raised Fish and Seafood 107 Fruit and Vegetables Juices 114 Genetically Modified Foods 120 Gluten125 Grains129

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Grass-Fed Beef 134 Green Tea 139 Guar Gum 143 Olive Oil 146 Organic Foods 151 Phosphorus-Containing Food Additives 156 Plant-Based Meats 161 Probiotics165 Raw Milk 168 Red Meat 173 Salt178 Saturated Fat 183 Soy187 Sugar Alcohols 191 Superfoods194 Vegetable Oil 198 Wine201 Xanthan Gum 205 Glossary209 Directory of Resources

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Index215

Introduction “An apple a day keeps the doctor away,” the old proverb goes, one that every kindergartener has recited for more than a century, and few people would argue that apples are not a healthy snack. It may surprise readers to learn that this saying did not originally spring from the marketing department of an apple growers’ association. In fact, the original aphorism comes from the Welsh town of Pembrokeshire and first appeared in print in 1866: “Eat an apple on going to bed, and you’ll keep the doctor from earning his bread.” Chances are that most parents do not take the apple prescription as medical advice, but the saying may give them enough pause that they select a shiny red apple for their child’s lunch bag instead of a pack of cookies. This may be considered a positive outcome, but it tells us a great deal about how we choose what we eat and whether we can and should trust the information presented to us as facts without knowing its origins. Innocent enough on the face of it, the apple-a-day expression made its way into the public consciousness and solidified its place there without a scrap of evidence to support its lofty claim. Apples became so synonymous with good health practices that in 2015, a team of three researchers at Dartmouth’s Geisel School of Medicine, the University of Michigan, and the Veteran Affairs Medical Center Outcomes Group completed an actual study “to examine the relationship between eating an apple a day and keeping the doctor away.” Can you guess what they found? Some 8,399 study participants filled out a dietary recall questionnaire, and just 9 percent of these turned out to be regular apple eaters. Comparing apple consumers with the others, the researchers reported no statistical significance between eating apples and the number of doctor visits, overnight hospital stays, or mental health visits the participants

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reported. The only real difference, the study concluded, was in the need for prescription medications: Apple eaters seemed to use fewer medications than those who did not eat apples. “Through the ages, the apple has come to symbolize health and healthy habits, and has been used by government and private health organizations to symbolize lifestyle choices that lead to health and wellness,” the researchers reported. This place in a balanced diet has not come about because the apple has some special health-giving property, but because its namesake proverb has been “promoted by the lay media and powerful special interest groups, including the U.S. Apple Association.” Most consumers will not parse their way through medical journals to find the studies that support or refute the claims of advertising slogans, but they may read websites, skim magazine articles, and watch videos and television news stories that take such research and boil it down to its essence. Some of these misinterpret the studies they cover, while others oversimplify the results. Still others convolute the information to serve their own purposes or to promote a specific diet or lifestyle as the answer to permanent weight loss and good health. And many others, especially special interest groups working for food industries, pay for research to be sure that it places their product in a positive spotlight. Debating Your Plate provides an overview of the ways in which influencers guide messages about the thousands of food choices presented to us and how these messages may mislead us. This book traces well-vetted research, questionable studies, marketing campaigns, biased and unbiased reporting, and media hype in an attempt to find some kernel of truth still remaining among the noise. I am a journalist, not a scientist, so I cannot draw final conclusions for readers; but I have presented as many sides to each discussion as I could find to help you become a more educated consumer of food industry information. If, in the end, you make healthier and more informed choices for your own plate, this book has done its job. As you will see from the Contents, the foods and food additives chosen here are those for which controversy continues, not those that have become matters of settled science. We know, for example, that trans fats are particularly harmful to the human body, and lawmakers have gone so far as to ban them in some U.S. regions. There is no need to debate this further, so trans fats, while mentioned in passing, do not get their own chapter. Nor does high-fructose corn syrup, another well-understood sweetener linked to many serious health issues. You will find a discussion of sugar in a section titled “The History of Food Controversies” and again in the chapter about fruit juices, but this book delves more directly into the question of artificial sweeteners and sugar alcohols, two hotly debated classes of ingredients. In a world where information from multiple sources bombards every consumer, we need to be vigilant about what we accept as fact and what is obviously meant to fool us. Debating Your Plate takes on a subject that affects every human being,

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helps you look beyond the headlines, and finds what you really need to know about the food you eat.

RESOURCE Davis, Matthew A., et al. “Association Between Apple Consumption and Physician Visits.” JAMA Internal Medicine, May 1, 2015, 175(5), 777–783. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420713

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Why Is Nutrition So Controversial? Hardly a day goes by without a new study emerging in the media, telling us that something is wrong with our food. A choice we believed to be healthy actually has the potential to ruin our good health. A favorite food turns out to be loaded with ingredients we already knew had to be consumed in moderation, tipping the scales toward harm if we dare to have an extra cookie or a second helping of potatoes. Experts, some legitimate and some self-proclaimed, tell us to consume more “superfoods,” but the list of these foods has become a moving target, with new, exotic-sounding ingredients rising to public consciousness on a regular basis. Unfamiliar fruits, vegetables, and grains are hailed as miraculous health-builders with the ability to prevent cancer, heart disease, diabetes, and more. Magazines and online articles urge people to cast away the foods we have eaten for centuries in favor of acai berries, goji berries, quinoa, freekeh, farro, bulgur, einkorn, spirulina, mangosteen, bee pollen, maca root, and many others—often long before science has caught up with these and other foodstuffs. Will this shift actually produce the promised results? Researchers rarely have the opportunity to delve into these claims before the ingredients arrive on store shelves, so marketers of these wonder foods may be the only ones to tout their superiority. Consumers looking for magical health boosts may frequent stores that specialize in nutritional supplements or take the word of a personal trainer or health-club owner, rather than seek the peer-reviewed science that might support or negate their claims. Here in the twenty-first century, it seems that something as basic as proper nutrition should be settled science. The 2015–2020 Dietary Guidelines for Americans (DGA), a publication based on decades of scientific research and published by the U.S. Department of Agriculture, provides sound nutritional advice

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that seems simple enough for households to follow. There is even a website, ChooseMyPlate.gov, that helps consumers build their own meal plan. Yet even as it provides the advice we need to pursue an informed diet and achieve lifelong health, the DGA notes that as many as half of all American adults live with chronic diseases related directly to the low quality of their dietary choices. What percentage of these people truly have no access to fresh foods and healthy choices and which are simply fast-food lovers cannot be gleaned easily from media reports and studies. We do know that 117 million people in the United States alone live with cardiovascular disease, high blood pressure, type 2 diabetes, cancer, and bone disease, all of which can be attributed directly to the foods they eat. “More than two-thirds of adults and nearly one-third of children and youth are overweight or obese,” the DGA’s introduction tells us: These high rates of overweight and obesity and chronic disease have persisted for more than two decades and come not only with increased health risks, but also at high cost. In 2008, the medical costs associated with obesity were estimated to be $147 billion. In 2012, the total estimated cost of diagnosed diabetes was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity.

So eating the wrong foods is making us sick, and these sicknesses are costing the American people a fortune. Is the DGA so difficult to understand that people can’t decipher it? Aren’t doctors giving this information to their patients to help them improve their own health? Or is something else afoot? Let’s take a look at what the guidelines call a healthy “eating pattern”—the foods that people tend to choose to eat and drink on a daily or weekly basis. A healthy eating pattern includes “all foods and beverages within an appropriate caloric level,” so an awareness of what constitutes a serving of each food becomes a critical component of balanced nutrition. Here are the elements of a healthy eating pattern named in the DGA: • Vegetables, with varieties including dark green, red, and orange, starchy, and legumes (beans and peas) • Fruits, including 100 percent fruit juices with no added sugar • Grains, with whole grains making up half of all grains consumed • Dairy—but only the fat-free or low-fat products, and including soy beverages • Proteins, including fish and other seafood, lean meats, lean poultry, eggs, nuts, legumes, seeds, and soy products • Oils of the monosaturated or polyunsaturated varieties

So far, it’s likely that nothing on this list comes as a surprise. We know that eating whole fruits and vegetables is a healthy choice, and wholesome grains, lean meats, poultry, and fish (or beans and nuts for vegetarians and vegans) are known elements in a well-rounded diet.

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The DGA continues, however, by setting significant limits on saturated fats, trans fats—the fats created by adding hydrogen to vegetable oil—sugar, and salt (sodium). These limits have been set using well-documented, peer-reviewed science that shows us that too much of these substances have a negative impact on human health. • Saturated fats are solid at room temperature and include the fat that marbles red meats, the fat found under the skin of poultry, and the fat in cream, lard, butter, full-fat cheese, and whole milk. The DGA recommends that we keep saturated fats down to 10 percent or less of our daily calories. • Trans fats, also known as trans-fatty acids, are largely created by an industrial process so that they retain their solid consistency at room temperature. This makes them last longer on the shelf than monosaturated and polyunsaturated fats, two kinds of fat that are necessary (in moderation) for a healthy diet. Trans fats increase the body’s LDL cholesterol—the bad kind—while lowering the good HDL cholesterol in a destructive double-punch to the human system. The Food and Drug Administration (FDA) recommends that we avoid products that use trans fats (look for “partially hydrogenated” in the ingredients list on packaged products and a trans fat listing in the nutritional breakdown). Most food packagers have stopped using them, but products including vegetable shortening, some microwave popcorn, some margarines and vegetable oils, fried fast foods, bakery products, canned frosting, piecrusts, nondairy coffee creamers, and some snacks still contain them. • The sugar added to processed foods—soft drinks, energy drinks, candy, cookies and other baked goods, flavored yogurt, ice cream, cereals, and some soups, bread, ketchup, processed meats, and so on—gets processed in the liver, which can be overwhelmed when a person consumes too much sugar. This leads to weight gain, fatty liver disease, high blood pressure, heart disease, and diabetes—and eventually to heart attack and stroke. The guidelines recommend that we consume less than 10 percent of our daily calories from added sugar. • The body needs sodium to control the balance of fluids as well as for the proper functioning of muscles and nerves. Too much of it, however, causes water to build up inside the blood vessels, which increases blood pressure. A level of 2,300 mg per day of sodium is recommended by the DGA.

It all looks simple enough, segmented in a way we can visualize as we load up a plate at a buffet or choose what to pack for lunch on our way to work. At the same time, every publication of the DGA (at five-year intervals since 1980) elicits backlash from the industries that produce the food we eat. Food manufacturers insist that the guidelines are too restrictive and that their industries are targeted unnecessarily. A similar response comes from the medical community, often saying that the guidelines are not restrictive enough and that more emphasis needs to be placed on reduction or elimination of specific foods. Still other organizations— some representing special interests like meat and dairy producers and others touting food group-elimination diets like keto and paleo—chime in with their own objections and research they may have commissioned to “prove” their own claims.

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Amid this cacophony, it can be difficult for journalists, researchers, and even peer-reviewed scientific journals to determine which points of view have merits and which are motivated by something other than the good health of the general public. Scientists face challenges of their own in attempting to understand which foods contribute to good health and which do not. Researchers encounter ethical conundrums in using humans as test subjects, making it virtually impossible to isolate a subject’s consumption of a specific food, nutrient, or ingredient to be sure that only this substance is causing a health issue. Imagine, for example, a study in which human subjects eat nothing but vegetable shortening (like Crisco or Spry) for weeks on end to see what harmful effects might emerge. Not only would the subjects exhibit health issues from consuming large amounts of trans fat, but they might very well develop diseases related to malnutrition: scurvy, rickets, anemia, beriberi, and pellagra, all of which signal vitamin deficiencies—and none of which are directly related to eating shortening. Worse, this abuse of their bodies might have the unintended consequence of jeopardizing their longer-term health. Instead, researchers test foods first using “in vitro” studies—that is, experiments in a laboratory using microbe-sized samples in test tubes or culture dishes; and then on “mouse models,” varieties of mice that share many of the same disease-causing genes that are present in humans. While thousands of studies of human diseases have begun with mouse models and have produced promising results, the studies eventually must move on to human subjects to determine if the results hold true. Designing studies that do not produce lasting harm to humans, obtaining funding for these studies, and then conducting them and reporting the results can take years, if not decades, to accomplish. In the interim, the findings of studies on mouse models may be published in peer-reviewed journals and then reported as decisive facts by the popular media. This can turn an inconclusive study into a dictum about a specific food or nutrient long before science is ready to do so. It is impossible, as noted earlier, to feed human beings just one food over the time it would take to produce the expected result, so human studies usually involve some kind of controlled diet that does not compromise the subjects’ overall nutrition. This may mean increasing the amount of the food to be tested, while maintaining a control group that eats none of that food. For example, the test subjects may consume a helping of quinoa three times a day along with their usual meal, while the control group eats no quinoa. The researchers may then perform medical tests at regular intervals to see how the quinoa affects the subjects’ health. This may sound like solid science, but it also has its obstacles to success. Researchers usually do not have the option of sequestering the test subjects and monitoring exactly what they eat for each meal; even if the subjects were willing to make this commitment, it would be tantamount to imprisonment (and likely cost prohibitive). In most cases, subjects keep a diary of their food intake, or they are asked to recall in periodic interviews what they ate some time before. As you

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might guess, this can result in omissions of information and forgotten foods and meals. If the study continues for a long period of time—some of these go on for years—subjects may drop out, decide they no longer wish to participate, move away, or even die. As if these issues did not make food studies hard enough to conduct, there are added levels of difficulty to deal with: Foods do not act in isolation in our bodies, and other things besides foods impact our health. Nutrients often work together to produce a beneficial effect: For example, to help the body absorb calcium, vitamin D must be present in sufficient amounts. As people eat a variety of foods at the same time and each of these foods may contain a wide range of ingredients, it can be very difficult to credit one food with a specific effect on the body. While many functions within the human body are well understood by medical science, no two people are exactly alike, and no one lives precisely the same lifestyle as anyone else. Health issues handed down genetically for many generations can make one person’s body behave quite differently from another one, changing the way the body digests, absorbs, and puts a food to use. People who are more physically active and fit than others may metabolize nutrients differently from someone who leads a sedentary life that results in obesity. Chronic medical conditions, food allergies, intolerances to dairy or wheat, imbalances in all the bacteria and other microorganisms in the gut (the microbiome), the presence of autoimmune disease, and a host of other issues can make one test subject very unlike another, producing widely skewed results. Into this din of conflicting opinions comes the consumer, trying to put healthy meals on the table for a family and confused about what “healthy” actually means. Even where the consumer buys food, new information catches the eye in the supermarket checkout line—magazine headlines that tout the latest secrets for weight loss or a way to add ten years to our lives: “Don’t Eat Anything White!” “Lose Five Pounds Overnight With This One Weird Trick!” “How These Three Superfoods Will Change Your Life!” And so many others. Are you baffled by this constant barrage of conflicting science, expert opinions, and fads? If so, it is working. Keeping consumers off-balance about the food they eat is part of the marketing plan for a wide range of weight-loss companies, food packagers, and professional associations that represent food producers and agriculture. The more they can cast doubt on the validity of basic nutritional guidelines, the more consumers will continue to question what they should and should not eat—and in this cloud of uncertainty, we are more likely to give in to our urges and eat that entire sleeve of cookies or order a bigger steak.

THE NUTRITION RESEARCH CONUNDRUM How are consumers supposed to determine what is solid science and what is the work of a special interest group? The line between the two has become fuzzy at best. Let’s take a very recent example: a study published in the Annals of

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Internal Medicine in October 2019 by Bradley C. Johnston, epidemiologist at Dalhousie University in Canada, and a team of more than a dozen other researchers from around the world. The study claimed that the link between red meat, heart disease, and cancer had never been proven conclusively by science, so people should not limit their consumption of beef and processed meats. This result drew immediate ire from health organizations and other scientists who had conducted their own published studies of red meat, but Johnston defended the legitimacy of the work and underscored that there were no conflicts of interest among his team—that is, no one on the research team worked for companies in the meat industry, and no industry organization had provided funds for the work. However, the New York Times reported just days after the study’s publication that Johnston had not disclosed that he had been a senior author on another published study several years earlier, one paid for by the International Life Sciences Institute (ILSI), “an industry trade group largely supported by agribusiness, food and pharmaceutical companies,” including McDonald’s, Coca-Cola, PepsiCo, and Cargill. That study attempted to discredit the science behind nutritional guidelines that advised people to eat less sugar. The Times quoted New York University professor Marion Nestle, who studies conflicts of interest in food research, in calling ILSI “a classic front group” for the food industry. “Even if ILSI had nothing to do with the meat paper—and there is no evidence of which I am aware that it did—the previous paper suggests that Johnston is making a career of tearing down conventional nutrition wisdom.” The Times sought out Christine Laine, MD, MPH, FACP, editor-in-chief of Annals of Internal Medicine, who pointed out that there are conflicts of interest on all sides of the meat issue, whether or not they had a hand in the study. “Many of the people who are criticizing these articles have lots of conflicts of interest they aren’t talking about,” she said. “They do workshops on plant-based diets, do retreats on wellness and write books on plant-based diets. There are conflicts on both sides.” She added that even if there had been a direct financial relationship between the study and a special interest group, the research methodology used still would have passed muster for publication. How, then, should the consumer process the information in the study? Is there such a thing as an unbiased study or an unbiased response to a controversial finding? These are difficult questions to answer, but they tell us a great deal about why we see so much controversy over the foods we eat and their potential effects on our overall health. A study funded by the industry that will benefit from its results—whether the industry is food, tobacco, coal, or running shoes—may produce sound scientific results, but if these results reach publication, they almost invariably favor the industry that funded them. “Food companies don’t want to fund studies that won’t help them sell products,” researcher Nestle told Vox in 2018. “So I consider this kind of research marketing, not science.”

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CLAIMS VERSUS REALITY Media reports on food studies rarely have unlimited space to provide clarifying detail, so the foreshortened summaries in newspapers, in magazines, and on websites usually reduce the message down to its tantalizing essence. This results in headlines like “11 Reasons Chocolate’s Good For You,” “Red Meat: It Does a Body Good!” and “Everyone Was Wrong: Saturated Fat Can Be Good For You.” As the message goes out to commercial and personal websites and to blogs, it gets even more distilled and distorted, until what began as coverage of research becomes wild claims of the miraculous properties of specific foods. Suddenly chocolate has “the highest antioxidants on the planet,” and red palm fruit oil will “extend the warranty of nearly every organ in your body.” Glancing at such headlines can send consumers spiraling off into unhealthy eating habits, all the while believing that they are doing the right thing for their bodies. In reality, they are simply taking the poetic exaggerations of nonexperts at their word, without reading the study—if there is one—or searching for the truth behind the claim. These stories feed the foibles of human nature, wish fulfillment that foods that delight our senses and deliver the highest overall satisfaction will also be healthy for us. It does not take much prodding from the media before consumers embrace the supposed health benefits of chocolate instead of foods we have known to be healthy for generations: cruciferous vegetables or leafy greens, perhaps, or a cup of sliced fruit. At the same time, the lure of the single food that will reset the body’s metabolic systems, clean out every toxin, and result in perfect health can spur consumers to buy products that make such claims but have no ability at all to accomplish these goals. Studies also rarely make conclusions about the size of a serving that will have the near-magical properties of improving health. Study after study crowing over the health-giving properties of dark chocolate, for example—nearly all of which are funded by Mars, Nestle, Hershey, or Barry Callebaut, some of the largest chocolate companies in the world—tout the beneficial effects of antioxidants, but gloss over the countereffects of the sugar and fat every piece of sweetened chocolate contains. Eating lots of dark chocolate will please the palate and may have some trace of positive effect, but the caloric intake and the high doses of sugar provide exactly the opposite effect, making the confection more of a health risk than a benefit.

HEALTHY OR NOT: LABELS MAY LIE Even foods that masquerade as healthy can pose dangerous challenges to our personal health goals. A comparison of low-fat and normal versions of packaged foods performed by researchers in 2016, for example, found that “the amount of sugar is higher in the low fat (i.e., reduced calorie, light, low fat) and non-fat than ‘regular’ versions of tested items.” Nguyen et al. revealed

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what the media already believed to be true: “The food industry may have replaced fat with sugar, which may be more obesogenic even if the calories per portion are less.” They found this to be true in low-fat dairy products, baked goods, meats, fish, poultry, fats, oils, and salad dressings—essentially in packaged foods in just about every category. This may be part of the reason that the eight-year Women’s Health Initiative Dietary Modification Trial, which followed the diet of nearly 49,000 women between the ages of fifty and seventy-nine from 1993 to 2001, showed that women on a low-fat diet did not lose weight, and thus did not lower their risk of breast cancer or cardiovascular disease. Many consumers find themselves in the same position, attempting to battle weight gain and avoid life-changing medical conditions by pursuing the 1977 guidelines to eat less fat, only to find the lowfat diet a complete failure for weight loss. These so-called healthy foods actually work against us, as the food industry quietly substitutes one ingredient for another in a bid to maintain delicious taste and texture, each food manufacturer’s most competitive advantage. The reaction of consumers to so much conflicting information may be to ignore the warnings they hear from the scientific community and even from their own doctors, giving them the same credence voiced by Mary Cooper, a character on the situation comedy “The Big Bang Theory”: “Doctors are always changing their mind. One week bacon grease is bad for you. The next week we’re not getting enough of it.” Balanced nutrition should be—and is—a fairly simple concept with some basic rules. It becomes complicated when science, marketing, and self-delusion come into play, conflicting forces that blur the lines between facts, fancy, and the quick-fix dreams of the average consumer.

RESOURCES Belluz, Julia. “Nutrition Research Is Deeply Biased by Food Companies. A New Book Explains Why.” Vox, Nov. 11, 2018. Accessed Jan. 13, 2020. https://www.vox.com /2018/10/31/18037756/superfoods-food-science-marion-nestle-book Crocker, Lizzie. “The Dangers of Superfoods.” The Daily Beast, Jul. 12, 2017. Accessed Jan. 13, 2020. https://www.thedailybeast.com/the-dangers-of-superfoods Howard, B.V., et al. “Low-Fat Dietary Pattern and Weight Change Over 7 Years: The Women’s Health Initiative Dietary Modification Trial.” JAMA, Jan. 4, 2006, 295(1), 39–49. Accessed Jan. 13, 2020. https://www.ncbi.nlm.nih.gov/pubmed/16391215 Nestle, Marion. “Perspective: Challenges and Controversial Issues in the Dietary Guidelines for Americans, 1980–2015.” Advances in Nutrition, Mar. 2018, 9(2), 148–150. Accessed. Jan. 12, 2020. https://academic.oup.com/advances/article/9/2/148/4969264 Nguyen, P.K.; Lin, S.; and Heidenreich, P. “A Systematic Comparison of Sugar Content in Low-Fat vs. Regular Versions of Food.” Nutrition & Diabetes, Jan. 2016, 6(1), e193. Accessed Jan. 13, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4742721/

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Parker-Pope, Tara; and O’Connor, Anashad. “Scientist Who Discredited Meat Guidelines Didn’t Report Past Food Industry Ties.” The New York Times, Oct. 4, 2019. Accessed Jan. 12, 2020. https://www.nytimes.com/2019/10/04/well/eat/scientist-who-discreditedmeat-guidelines-didnt-report-past-food-industry-ties.html U.S. Department of Agriculture. Dietary Guidelines for Americans 2015–2020, Eighth Edition. Office of Disease Prevention and Health Promotion. Accessed Jan. 12, 2020. https://health.gov/dietaryguidelines/2015/guidelines/

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The History of Food Controversies People have most likely debated the merits or perils of various foods since they first began to communicate with one another. We can imagine the earliest human beings arguing over the benefits of one animal’s meat over another or disagreeing over which berries were tastier and which could actually kill a person with poison. The fact that some people have a gene that makes cilantro and arugula taste like soap points to a likely source of disagreement over dinner tables for centuries, but we have no way to prove this beyond common sense and conjecture. Author Mark Kurlansky attempted to codify one of the earliest food controversies in his book Milk! A 10,000-Year Food Fracas. The debate centered on cheese, emerging as far back as the first written records of Greek civilization. Hippocrates, considered to this day to be the father of modern medicine, wrote in the fifth century BC about the hazards of eating cheese: “Cheese does not harm all people alike, and there are some people who can eat as much of it as they like without the slightest adverse effects. Indeed it is wonderfully nourishing food for the people with whom it agrees. But others suffer dreadfully. . .,” perhaps revealing the first awareness of the symptoms of lactose intolerance. A few centuries later, Anthimus, a Greek man of AD 500s, both agreed and disagreed with Hippocrates’s early assessment. “Whoever eats baked or boiled cheese has no need of another poison,” he wrote, going on to declare that cured cheese caused kidney stones, while fresh cheese was unlikely to cause any harm. His perspective echoed other writers that had set down their thoughts about cheese even earlier in the millennium, some declaring aged cheese to cause stomach agonies of many varieties, while others said that it actually assisted digestion. Cheese is a product of milk, of course, so which milk provides the most nutritional value quickly became a side discussion. Greeks and Romans debated

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whether goats, sheep, or donkeys provided the most nourishing milk for babies (after mother’s milk or the milk of a wet nurse) and whether or not milk would rot a human’s teeth. In 1775, French doctor Alphonse Leroy delved into the causes of a high percentage of infant deaths in a hospital in Aix and concluded that the babies died from artificial feeding with animal milk, which spoiled quickly after being harvested from the animal. The discovery of pasteurization in the 1880s removed this hazard from animal milk, but the debate over the merits of breastfeeding versus artificial feeding continues today. Meanwhile, as more people migrated from rural areas into the big cities and had to shop at markets for the food they ate, packaged products took a dark turn. Food producers from dairies to meat packagers found ways to make inferior foods look tasty and last longer on shelves, compromising health to disguise rancid, spoiled, or otherwise unpalatable milk, meat, butter, honey, syrup, and many other foods. The use of fillers and additives also extended the supply of each food, allowing packagers to make more money with less actual product. Unsuspecting consumers had no idea that they were eating brick dust instead of cinnamon, the cleaning product borax in their butter, salicylic acid in beer and wine, corn syrup instead of honey, and the poisonous preservative formaldehyde in milk and meat. As he saw people becoming ill with strange symptoms, Dr. Harvey Washington Wiley, the chief chemist of the U.S. Department of Agriculture, determined that an investigation into the true contents of food and drink was necessary. He formed a cadre of brave volunteers that became known as The Poison Squad, young men who agreed to eat specific foods prepared for them at every meal for an extended period of time and take capsules filled with substances that were being used as preservatives and additives in many foods. Wiley then tested the men to determine the effects of these chemicals on their health. Not surprisingly, the young men showed all kinds of symptoms of illness, especially when Wiley fed them formaldehyde. “We like to think of our greatgrandparents as pink-cheeked eaters of nothing but the finest food,” said Deborah Blum, author of The Poison Squad: One Chemist’s Single-Minded Crusade for Food Safety at the Turn of the Twentieth Century, to Karl Knutson at the University of Wisconsin at Madison in 2019. “But they were eating fake, poisonous food full of really bad things.” Despite the startling results of his experiments, it took years before Wiley convinced enough people that the food industry was actively poisoning Americans. He finally managed to ensure the passage of the Pure Food and Drug Act of 1906, which required truth in food labeling and banned the nefarious practices so many food manufacturers had instituted. In 1912, Kazimierz (Casimir) Funk, a Polish scientist, was the first to determine that foods contained “vital amines,” which he later shortened to vitamins, substances that nourished the body and contributed to good health. His work led to the discovery of thiamine (vitamin B1), riboflavin (B2), niacin (B3), and vitamins C and D, each of which played a role in preventing single-nutrient deficiency diseases like scurvy (vitamin C), beriberi (B1), pellagra (B3),

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rickets (D), and pernicious anemia (B12). All of the major vitamins had been identified and named by the middle of the twentieth century—remarkably, just in time for the Great Depression and World War II, when governments around the world faced the very real possibility of food shortages. The German submarine warfare campaign during World War I had culminated in widespread grain shortages across Europe, as countries dependent on imports were cut off from their suppliers. Food-rationing programs had saved lives in Britain, France, and Italy, but no one wanted to see a repeat of this. The ongoing conflict with Germany throughout the 1930s indicated that another massive war was on the horizon. The looming crisis led the League of Nations, the British Medical Association, and the U.S. government to take an important step. They each determined the recommended daily allowances (RDAs) of nutrients for the human diet as well as the caloric intake to maintain a healthy weight. In addition to vitamins, the RDAs addressed nutrients including calcium, iron, protein, and phosphorus, establishing minimums required for soldiers on the battlefield as well as for citizens at home. The National Nutrition Conference for Defense presented these guidelines in 1941, and the Journal of the American Medical Association (JAMA) published them as well, making the information readily available to the global medical community. For the first time, food’s role as the primary delivery system for nutrients became well understood by the general public as well as by the scientific and medical communities. Which foods packed the most nutritional punch, however, and which might actually be bad for us would become the hotly contested domain of food growers, manufacturers, packagers, and their marketing departments. Manufacturers moved quickly to find ways to synthesize nutrients and fortify products with vitamins and minerals they did not normally contain. They developed processing methods that purified staples like wheat and rice, making them more shelf-stable and better able to carry synthetic nutrients. These products boosted the nutritional content of foods imported by poorer and developing countries, helping to alleviate some of their dietary issues, while giving consumers in richer countries more choices for their own families’ nutrition. After World War II and the resumption of import–export activity around the world, nutrition scientists turned their attention to noncommunicable diseases beyond those caused by vitamin deficiencies. Coronary heart disease (CHD) had become a leading cause of death in nations with an abundance of food choices, particularly in American men. This led to many studies of the role of various dietary issues in causing CHD, from fats and cholesterol to carbohydrates— including sugar, a simple carbohydrate that boosts mood and acts as a source of quick energy, but also inflames fat cells and leads to rapid weight gain. Studies also examined the role of all of the known vitamins and minerals, plant-based substances called phytosterols that we now know can help lower LDL cholesterol, and amino acids.

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Research in the 1950s divided the scientific community on whether dietary fats or sugar contributed more strongly to the development of these diseases. John Yudkin’s research revealed that added sugars are the primary cause of heart disease, while Ancel Keys determined that the combined total of saturated and other kinds of fat, as well as cholesterol, played an equally significant role. As evidence mounted that sugar might be a greater heart disease trigger than fat and cholesterol, the sugar industry took steps to keep this information from coming to light. In 2016, a research team led by Cristin E. Kearns, DDS, MBA, discovered 1,551 pages of documents in the University of Illinois Archives that included correspondence between the Sugar Research Foundation (SRF) and one of its scientific advisors, Roger Adams, written between 1959 and 1971. The team also found documents that passed between the SRF and D. Mark Hegsted, professor of nutrition at the Harvard School of Public Health, who codirected the SRF’s research on CHD in 1965 and 1966. The correspondence said that the SRF’s scientific advisory board knew in 1962 that sugar could elevate cholesterol, even if people maintained a low-fat diet. By 1964, laboratories had discovered that sugar was a greater hazard to human health than other carbohydrates, replicating Yudkin’s research. The SRF’s vice president and director of research, John Hickson, recommended that the SRF “embark on a major program” to counteract “negative attitudes toward sugar.” He suggested opinion polls, symposia to unveil fallacies behind the research, and a review of all the research to date to “see what weak points there are in the experimentation, and replicate the studies with appropriate corrections. Then we can publish the data and refute our detractors.” This started a systematic and highly effective effort to undermine findings of studies throughout the 1960s that linked sugar to CHD. The effort, known as Project 226, involved an extensive literature review titled “Dietary Fats, Carbohydrates and Atherosclerotic Disease,” published in the New England Journal of Medicine in 1967, in which the authors did not disclose the involvement of the SRF. “The review concluded there was ‘no doubt’ that the only dietary intervention required to prevent CHD was to reduce dietary cholesterol and substitute polyunsaturated fat for saturated fat in the American diet,” Kearns et al. wrote. “Overall, the review focused on possible bias in individual studies and types of evidence rather than on consistency across studies and the coherence of epidemiologic, experimental and mechanistic evidence.” In short, to protect market share for the sugar industry, the report led the medical community and the general public to believe that sugar played no significant role in CHD and that fat was the real culprit in clogging arteries with cholesterol. When this effort succeeded in focusing negative attention almost entirely on fat, SRF moved on to attempt to refute the fact that sugar contributed in large measure to tooth decay, though this effort did not meet with the same success.

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MANY INDUSTRIES, MANY CONTROVERSIES If this had been an isolated incident, the world’s population might be far less confused over what they should and should not eat to maintain good health over a lifetime. The misleading sugar information, however, is just one of many efforts to protect the profit-making abilities of various segments of the food industries by informing the public that specific foods have properties that make them healthier than others, even when research does not bear these conclusions out. The Sugar Association, the modern reorganization of the SRF, continued its campaign to make the public believe that not only was refined sugar a safe ingredient, but it was actually good for us. Just as the link between sugar and diabetes became well understood, a 1970s advertising campaign touted sugar as an important aid to dieting, with headlines like “Sugar can be the willpower you need to undereat.” Another ad suggested that the way to “get ready for the fat time of day,” referring to when people allow themselves to get very hungry, was to eat more sweets. “By snacking on something sweet shortly before mealtime, you turn your appestat down,” the ad said, referring to an area of the brain that controls the appetite. “The sugar in a couple of cookies or a small dish of ice cream can turn it down almost immediately.” The scientific-sounding solution to hunger seems absurd now, but it gained some credence at the time, leading to even more perverse claims by the industry. “If sugar is so fattening,” an ad dominated by an image of a bubbling cola drink over ice asked, “how come so many kids are thin?” A Milky Way candy bar commercial suggested that viewers should have a bar “whenever you’re in the mood—it tastes like chocolaty candy, but it’s really nourishing food! Oh, there’s farm-fresh milk in a Milky Way and whipped-up egg whites, too.” It ended by calling Milky Way “the Good Food Candy Bar!” At the same time, a major shift took place in people’s diets. Processed food began to overtake homemade dishes, spurred by the convenience of purchasing a packaged product and the wide availability of fast food in all but the most remote communities. The ability to feed a family in minutes and do so economically— just as the women’s liberation movement saw many women reducing or rejecting their homemaker role and pursuing careers—changed the way people ate and altered the nutritional content of each meal and snack. Obesity rates began to soar, even in some of the poorest nations in the world. Hypertension, heart disease, and diabetes grew and spread throughout the world with a prevalence never seen before. Amidst this proliferation of chronic diseases, the U.S. government presented its first Dietary Guidelines for Americans, a set of rules that are updated every five years to accommodate the most recent understanding of nutrition. These first guidelines seem almost quaint today with their basic advice: “Eat a variety of foods; maintain ideal weight; avoid too much fat, saturated fat and cholesterol;

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eat foods with adequate starch and fiber; avoid too much sugar; avoid too much sodium; if you drink alcohol, do so in moderation.” The overly simplistic direction led the food manufacturing and packaging industry to bolster the nutritional value of its products with synthetic vitamins and minerals and to make substitutions in ingredients to reduce the amount of saturated fat. Consumers readily believed that the low-fat cookies they bought were healthier than their standard choices, never suspecting that the excellent flavor and texture they enjoyed had been created by doubling the sugar or by adding sugar products like high-fructose corn syrup. Preservatives in frozen and canned foods lengthened shelf life but had a negative effect on the food’s healthfulness. Soaring sodium content provided the flavor consumers craved, but led to hypertension and kidney failure. Replacement of saturated fat with partially hydrogenated vegetable or tropical oils led to the proliferation of trans fats, which have since been found to reduce HDL (good) cholesterol while dramatically increasing LDL (bad) cholesterol—making them even worse than the fats they replaced. In the end, many of the products advertised as healthier choices were no better for the human body than their original counterparts, and some actually did more harm than good. With new knowledge and a stronger understanding of the hazards of the modern diet, it might seem that people should be making better choices based on sound principles of nutrition and health . . . but this is not necessarily the case.

BACK-TO-NATURE DIET FADS Some foods are healthier than others—no one would dispute this fact. The idea that some foods provide a knockout punch to disease and supply all of the nutrition the body needs in a single bite, however, is a fantasy at best. This has not stopped the marketing departments of food producers and diet purveyors from attempting to sell their products as the best alternatives for a lifetime of blissful good health. After several decades loaded with processed foods and their additives, consumers have seen the negative effects that a steady diet of such products has had on their bodies. Moving away from bad habits and embracing a healthier, more natural diet would undoubtedly provide a better path to wellness, but consumers were left to seek a new direction on that path for themselves . . . until the next age of food marketing caught up with them. Enter the designer diets that center on raw foods and food group elimination, touting foods served and eaten in their natural state, with anything processed (or, in some cases, anything cooked) treated as evil—unless, of course, it has the diet’s brand name on it. Atkins, keto, paleo, and South Beach diets all eliminate carbohydrates except for small portions of fruit and vegetables, but instead of centering on lean proteins as healthier choices, they encourage a significant increase in

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saturated fat—a risky proposition because of its well-known link to heart disease. Some of these diets also feature packaged products that bear the diet’s logo, from snacks to full meals, each with its nontrivial price tag. These diets have been known to exacerbate liver and kidney disease by overwhelming these organs with hard-to-digest fats, while leading to nutrient deficiencies from reductions in fruit, vegetables, and grains. “Power foods” emerged as well, grouping specific fruits, vegetables, grains, and nuts with manufactured products like fortified bottled water and a tangy yogurtbased drink called kombucha. Some foods made “top 10” lists, signifying them as the healthiest things a person can eat or foods touted to aid in weight loss, increase energy, or even reverse heart disease and diabetes. Can there be truth to these claims that all the vitamins, minerals, and other nutrients we need have been right here under our noses all along—and all we need to do is eat these five or ten or twelve amazing things and forsake everything else? How can we be sure that following the advice of the latest studies and headlines will be good for us—or at least not bad for us? This book endeavors to break down these and many other food controversies to better understand which messages have a basis in fact and which are nothing more than marketing hype. While this book does not attempt to bring any of these disputed issues to an absolute conclusion, the analysis may help readers recognize a dubious claim and apply a critical eye and ear to the next story they may want to believe, but that simply doesn’t carry that ring of truth.

RESOURCES “Antioxidants and Cancer Prevention.” National Cancer Institute. Accessed Jan. 16, 2020. https://www.cancer.gov/about-cancer/causes-prevention/risk/diet/antioxidants-fact -sheet Blum, Deborah. The Poison Squad: One Chemist’s Single-Minded Crusade for Food Safety at the Turn of the Twentieth Century. New York: Penguin Random House, 2019. Garber, Megan. “If Sugar Is Fattening, How Come So Many Kids Are Thin?” The Atlantic, June 19, 2015. Accessed Jan. 16, 2020. https://www.theatlantic.com/entertainment /archive/2015/06/if-sugar-is-fattening-how-come-so-many-kids-are-thin/396380/ Kearns, Cristin E.; Schmidt, Laura A.; and Glantz, Stanton A. “Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents.” JAMA Internal Medicine, Oct. 3, 2018. Accessed Jan. 16, 2020. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC5099084/ Knutson, Karl. “Go Big Read Book ‘The Poison Squad’ Offers Food for Thought.” W News, University of Wisconsin-Madison, Oct. 9, 2019. Accessed Mar. 12, 2020. https://news.wisc.edu/go-big-read-book-the-poison-squad-offers-food-for-thought/ Kurlansky, Mark. Milk! A 10,000-Year Food Fracas. New York: Bloomsbury Publishing, 2019. Mozaffarian, Dariush, et al. “History of Modern Nutrition Science—Implications for Current Research, Dietary Guidelines, and Food Policy.” BMJ, June 13, 2018, 261(2392). https://www.bmj.com/content/361/bmj.k2392

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“Nutrition and Your Health: Dietary Guidelines for Americans.” U.S. Department of Agriculture, 1980. Accessed Jan. 16, 2020. https://health.gov/dietaryguidelines/1980thin. pdf?_ga=2.55721323.1311854758.1579207439-1493036851.1578858966 O’Connor, Anahad. “How the Sugar Industry Shifted Blame to Fat.” The New York Times, Sept. 12, 2016. Accessed Jan. 16, 2020. https://www.nytimes.com/2016/09/13/well/eat /how-the-sugar-industry-shifted-blame-to-fat.html “Should You Try the Keto Diet?” Harvard Health Publishing, Harvard Medical School, Dec. 12, 2019. Accessed Jan. 27, 2020. https://www.health.harvard.edu/staying-healthy /should-you-try-the-keto-diet

How to Evaluate Nutrition Research and Health Claims New information about nutrition makes headlines almost every day, whether it is found in a national newspaper, on a respected news website, in a medical journal, or on a blog of uneven reputation. It can be exceedingly difficult for the average consumer to understand if we should take the information with a grain of salt or if we should embrace it as the new normal. Which information is reliable, and which is a carefully veiled marketing message from a food company? How can we tell credible science from slick packaging? Most people struggle to tell the difference, while others simply accept anything they see in the media as established fact. “Nutrition research is complex, and is often oversimplified by the media,” said an article from the Harvard T.H. Chan School of Public Health. “Writers may report on a single preliminary study that is unverified by additional research, or highlight a study because it contradicts current health recommendations—the goal being an attention-grabbing headline.” Generally, each new scientific study is another step toward gaining an understanding of how the body works and how nutrients affect it, but no single study is the absolute final word on science. Research continues at universities and other institutions around the globe on a daily basis, with each new finding providing a small advancement or a small setback in our knowledge. We as consumers tend to seek the once-and-for-all truth about what we should be eating and how much of it we should eat to achieve a desired result, but there may never be a single answer to these questions—and the answer may be different from one individual to the next. Different kinds of studies may test the same hypothesis and yield different results. This may be because one study’s methodology is more solid and reliable

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than another or because one study involved thousands of cases, while another used a very small sample group. In some cases, the contradictory studies are equally credible, but the research arrived at different conclusions—and this leads to more questions and more research to understand why. News headlines meant to increase viewership or grab a reader’s attention can color our judgment as well. “Fruits and Vegetables Are Trying to Kill You,” an article in the ezine Nautilus proclaims, when the text of the article discusses how plant-based eating improves health by providing antioxidants that neutralize free radicals in the body. “Chocolate Can Save Your Life,” a headline in the Independent, a newspaper in the United Kingdom, told its readers, espousing the effects of antioxidants and the limited effect those in chocolate might have in preventing cancer. The website for People for the Ethical Treatment of Animals (PETA) carries this story: “Here’s Why Eating Fish Is Actually Really Bad For You,” portraying all fish as laden with mercury and PCBs (banned since 1977) and therefore virtually poisonous. All of these stories have their basis in research, but their meaning has been distorted to lure readers—and in at least one case, to advance a special interest agenda. “What’s missing from the increasingly fast-paced media world is context,” Harvard’s T.H. Chan School tells us. “Diet stories in the news often provide little information about how the newly reported results fit in with existing evidence on the topic, which may result in exaggerating the new study’s importance.” Before taking any news report about a research study at face value, consumers can develop their own ability to read and listen critically and to determine if the study has merit, if it is a shill for a corporation or industry’s interests, if it is simply nonsense, or if they should seek additional information before accepting its findings. Here are some guidelines to follow to help you become a more critical reader of scientific research in all its forms. 1. What kind of study is this? There are many kinds of studies, and some are much more likely to produce an accurate result than others. a. Meta-analysis combines data from a number of already completed studies to arrive at a conclusion. This method can strengthen the validity of the results because there are more subjects involved, increasing the study’s diversity and delivering a more statistically significant result. b. Systematic review. This process, also known as a literature review, is usually conducted by a panel of researchers who review all of the studies on a specific topic and compile a report for publication. The report summarizes the findings of each study and draws one or more conclusions about the data overall. Some such reviews do not take into account the widely varying methods used by the many studies, which may have led to very different results. Systematic reviews should screen out studies that are outliers because of their research methods or a major difference in focus, using only the studies that are relevant to the specific question asked by the review. c. Randomized controlled trial. The most credible and often the costliest of the many study designs, the randomized trial assigns subjects randomly to either an experimental group or a control group. The experimental group tests whatever the variable

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is—a new drug, a specific diet, a practice like exercise or therapy—while the control group does something else or does nothing at all. This allows the researchers to determine if the specific variable has an effect on the experimental group, in comparison to those who did not have that variable. The clear identification of the participants, the ability to screen out other variables, and the randomization all make this the most reliable form of research. d. Cohort study. Sometimes short term and sometimes continuing for years or decades, the cohort study follows a specific group to determine its risk factors for a disease, a condition, or another result. People in the study usually share similar characteristics (e.g., women in their twenties who all weigh between 120 and 140 pounds). The study introduces a variable—like adding an avocado per week to their diet for a year—which in turn becomes a risk factor with a potential outcome. The researchers then monitor the cohort’s compliance with the study variable, collect data, and determine the effect of the variable at the end of the study. There can be drawbacks to cohort studies, however: They may take place in a contained geographic area where other variables can interfere with the outcome or the cohort itself may not be random enough to produce a valid result. e. Case control study. Here no actual variables are tested. The study is based on observation of subjects selected because they already have a specific disease, condition, or lifestyle. The study examines the subjects’ past behavior after the fact to determine if the behavior affects the disease or condition. Because this kind of study attempts to trace the cause after the effect is known, it must rely on the subject’s recollection of things he or she did days, months, or years before. The result may be biased by coincidences, triggering the fallacy post hoc ergo propter hoc—which translates to “after that, therefore because of that.” For example, a study may look at people with cancer to determine how much red meat they ate before their diagnosis. The results would rely on people’s memory of how often they ate burgers or steak over the course of years, without taking into account other factors like a genetic predisposition to cancer, exposure to environmental factors, and other potential causes of their condition. f. Case report. Not strictly a study, a case report is an article that describes a specific incident or subject, usually one that is an outlier or is otherwise unique. It may, for example, examine the case of a woman who eats avocados every day and who also develops rosacea, a rosy skin condition on her face. These two things may or may not have anything to do with one another, but the case report may work to draw parallels between these two disparate things. If other scientists or doctors have observed the same variables, they may read the case report in a journal and contact the scientist who wrote the paper, which may lead to a case control study and, eventually, a randomized trial. 2. How many studies are involved? A single study rarely provides all the information the scientific community needs to declare its results to be unshakingly valid. This is especially true if the study is actually a case report about one individual or a case control study that attempts to piece together behavior from memories. These studies may indicate the need for additional research, but they cannot be taken as the final word. 3. Who paid for the study? Most peer-reviewed journals require researchers to disclose the funders of their studies, which will be either mentioned in the study abstract or listed at the end of the publication. Studies may be highly suspect if they provide these

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funders with the scientific data they need to declare their products to be miraculously healthy. This may be the most telling aspect of whether you as a consumer should take the study’s findings to heart. As we have seen earlier in this book and will see again going forward, food industry executives have a great deal invested in keeping their products on the market, and some will pay to boost their claims of healthiness and bury the truth about the potential negative effects of their own products. This is the very definition of conflict of interest in food science. Such studies can certainly produce plausible results if the methodology is sound and if the food industry association remained hands-off, providing the funding but allowing the researchers to come to data-driven conclusions on their own. It is up to the peers who review these studies before publication to determine the level of involvement the funders had and if they interfered in the results in any way. Publication does not automatically mean that there is no bias, but it can be a good indicator that the review committee found the research to be credible. 4. Are the subjects humans or animals? Dietary studies may not always involve human subjects. Animal studies often come before human studies, but their results may not translate to humans and should not be taken as the final word on the health benefits of a specific food, diet, medication, therapy, or any other practice. Ninety-five percent of studies use mice or rats, in part because their genetic and biological characteristics are remarkably similar to humans—and scientists can breed “transgenic” mice with genes that are very like the ones that cause diseases in people. Not every result achieved in rodents can be duplicated in a human being, however; researchers will move on to studies with humans if their results are exciting enough to bring them more funding. 5. How big a study is it? A study involving just a few subjects may be more anecdotal than scientific, as the sample may not be statistically significant. Larger studies usually provide more dependable results, but they can be very costly to develop and manage, making it difficult for a university or independent research organization to acquire funding until they can point to significant results from a smaller study. 6. What protocols are in place? Be wary of so-called research that takes place outside of a well-controlled scientific setting. People who are not university researchers can have good ideas, of course, but slapdash studies do not yield reliable results, no matter how passionate the researcher may be. (One study discussed in this book took place in the researcher’s home kitchen and does not pass for scientific rigor.)

Nutrition science continues to evolve, so what we believed to be fundamentally sound one day may be flipped on its head by new research the next. We learned in the 1970s, for example, that eating eggs increases the body’s cholesterol level, which can lead to heart disease. Equally credible research in 2015 then told us that eggs’ nutritional content outweighs their negative effects, allowing them to re-enter the Dietary Guidelines for Americans in 2015 as a good source of protein. In 2019, however, research published in JAMA found a direct association between consuming one and a half eggs daily and development of heart disease, even leading to early death. Were we bamboozled by bad information back in the twentieth century? Or has science improved and moved on, giving us better data? The clear answer is the latter one: Science keeps improving, as jarring as it may be to have our

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“common knowledge” ripped away from us repeatedly over time. It is up to us as consumers of information to learn to distinguish between good science and marketing schemes, between solid research and self-interest, and among too-good-tobe-true claims, scare tactics, and provable facts.

RESOURCES “Diet In the News—What to Believe?” Harvard T.H. Chan School of Public Health. Accessed Jan. 17, 2020. https://www.hsph.harvard.edu/nutritionsource/media/ Melina, Remy. “Why Do Medical Researchers Use Mice?” LiveScience, Nov. 16, 2010. Accessed Jan. 19, 2020. https://www.livescience.com/32860-why-do-medical-researchers -use-mice.html Nagler, Rebecca. “Adverse Outcomes Associated with Media Exposure to Contradictory Nutrition Messages.” Journal of Health Communication, 2014, 19(1), 24–40. Accessed Jan. 17, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353569/ Powell, Denise. “Health Effects of Eggs: Where Do We Stand?” CNN, Mar. 27, 2019. Accessed Jan. 17, 2020. https://www.cnn.com/2019/03/27/health/eggs-good-or-bad -where-do-we-stand/index.html “Study Design 101.” Himmelfarb Health Sciences Library. Accessed Jan. 17, 2020. https:// himmelfarb.gwu.edu/tutorials/studydesign101/

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Foods and Ingredients

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Artificial Flavorings WHAT ARE THEY? All matter in the universe is composed of chemicals—the air we breathe, the clothes we wear, the chair you’re sitting in now, the scenery or objects around you, and the foods we eat. If you can see any object and touch it, taste it, or smell it, you can be certain that it is made of chemicals. Our bodies contain all kinds of chemicals that make up our organs, bones, and even our thought processes. Oxygen, nitrogen, carbon dioxide, salt, water, blood, urine, bile, serotonin, dopamine, all kinds of electrolytes, and all of the other substances that make our bodies function are vital chemicals, required for life to exist. The aroma and flavor of all foods come from each food’s chemical makeup and its ability to activate the senses of both smell and taste. Some are volatile chemicals that evaporate and enter our nostrils, allowing us to inhale the food’s scent. The sense of smell plays an important role in aiding the sense of taste—in fact, taste is our most limited sense, with taste buds in the tongue acting on just four components in food: sweet, salty, sour, and bitter (though there has been considerable discussion about “umami,” a Japanese word for the taste of meaty foods, that also seems to activate selected taste buds). The combination of the senses of smell and taste creates flavor, the more intense experience of a food beyond the basics the tongue can discern on its own. For more than a century, the food industry has researched and determined ways to increase the tastiness in foods, making the flavor as enticing as possible to keep consumers coming back for more. Artificial flavorings play a significant role in this, by distilling a flavor down to its essence—the chemicals known as esters, which provoke the strongest recognition by the taste buds—and increasing the use of this core flavor component in a specific food. Some of these chemicals occur naturally, while others can be created in laboratories from combinations of synthetic chemicals. The U.S. FDA’s Code of Federal Regulations, Title 21, Chapter 1, defines an artificial flavoring as “any substance, the function of which is to impart flavor, which is not derived from a spice, fruit or fruit juice, vegetable or vegetable juice, edible yeast, herb, bark, bud, root, leaf or similar plant material, meat, fish, poultry, eggs, dairy products, or fermentation products thereof.” In other words, any flavoring that does not come from the natural source of that flavor is considered artificial. Both artificial and natural flavors may be created in laboratories, but the ingredients used to create the flavor may come from natural sources like those listed by the FDA or from both natural and artificial sources. Few flavorings can

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succeed if they have none of the original food’s natural essence: A strawberryflavored hard candy, for example, must derive its flavor from the essence of a strawberry, at least in part. “There is little substantive difference in the chemical compositions of natural and artificial flavorings,” writes Gary Reineccius, a professor of food science at the University of Minnesota. They are both made in a laboratory by a trained professional, a “flavorist,” who blends appropriate chemicals together in the right proportions. The flavorist uses “natural” chemicals to make natural flavorings and “synthetic” chemicals to make artificial flavorings. The flavorist creating an artificial flavoring must use the same chemicals in his formulation as would be used to make a natural flavoring, however. Otherwise, the flavoring will not have the desired flavor. The distinction in flavorings—natural versus artificial—comes from the source of these identical chemicals and may be likened to saying that an apple sold in a gas station is artificial and one sold from a fruit stand is natural. (Reineccius, 2002)

The difference, then, comes from where the chemical itself originates. Collection of some flavors from their sources in nature can be costly and, in the case of some exotic flavors, destructive to fragile plants or crops that may be difficult to cultivate and maintain. Researchers have found ways to synthesize the same ester in a laboratory, often duplicating the plant’s ester exactly using the same chemical elements to create the compound. The flavor may be identical, but the compound originated in a lab, so the FDA defines it as artificial.

CURRENT CONSUMPTION STATISTICS AND TRENDS Estimates indicate that 90 percent of processed foods—the packaged products we purchase in grocery stores—contain artificial flavorings, making them absolutely pervasive in our food supply.

NUTRITIONAL INFORMATION Generally, artificial flavors have little to no nutritional value. They serve the purpose of making food taste good, but they do not add vitamin or mineral content.

HISTORY Spices, herbs, and other flavorings have been part of the human consciousness for thousands of years, but the ability to create artificial flavors came about in the 1800s, when businesses in Germany and Switzerland found ways to extract naturally occurring flavors from plants. They began to export essential oils, which

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contained pure esters, as well as flavor extracts that used alcohol or other carriers to increase the volume of a concentrated flavor. By the turn of the twentieth century, food manufacturers and packagers began to spring up in the United States at a great rate, so some enterprising Americans who had imported German and Swiss flavor products—mostly in New Jersey— opened their own laboratories. As there has never been a shortage in demand for flavors, these labs continue to turn out new, interesting products to enhance the taste of processed foods. Today artificial flavors are used in thousands of packaged foods, with the market for lightly flavored sparkling waters one of the newest popular uses for these chemical compounds. In 1938, after 100 people died when they took a popular drug containing a new, untested additive called sulfanilamide, Congress passed the Federal Food, Drug, and Cosmetic Act, requiring that all substances used in food and drugs be categorized and assessed for safety—and over the years, this law has been amended many times to make its enforcement less unwieldy. One such change was the 1958 Food Additives Amendment, which required that all food additives be approved as safe before coming to market. (More on how this works in “The Controversy” section.)

THE CONTROVERSY Food labels tell consumers when artificial flavors have been used to create the products they buy, so it’s no secret that most packaged products contain flavors synthesized in a laboratory. It is important to read beyond the ingredients to see how the manufacturer positions and modifies the product name and description, as this tells consumers a great deal about whether the product comes by its flavors naturally or via the lab. “Blueberry yogurt” may be flavored with actual blueberries, for example, while “blueberry-flavored yogurt” probably contains a substance that includes a synthesized blueberry flavor. The larger questions, however, are whether any of these flavorings are somehow harmful to consumers or whether food manufacturers are using these flavors to trick the human body into craving more, thus luring consumers to want more of a specific cookie, candy, or chip. As far back as 1959, the Flavor and Extract Manufacturers Association of the United States (FEMA) saw the need to establish a program through which professionals in the flavoring industry could determine the safety of the many artificial flavors proposed for use in food products. As such a testing operation had never existed before, an expert panel came together in 1960 to create a standardized program for assessing the safety of these substances, “including the use of metabolic studies and structural relationships that had not previously been applied in a significant manner to food ingredients before the Panel did so in the 1960s,” according to FEMA’s website. As a result of this rigorous review, artificial flavorings earned the status “Generally Regarded as Safe” (GRAS). This status

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means that a food ingredient has met the four criteria stated by FEMA (https:// www.femaflavor.org/gras): 1. General recognition of safety by qualified experts. 2. The experts must be qualified via training and experience to evaluate the substance. 3. The experts must base their determination of safety on scientific procedures or on common use in food prior to 1958, when the program began. 4. The GRAS determination must take into account the conditions of intended use: for example, its function as a flavoring in food.

A food manufacturer cannot simply say that this review took place and the food is safe; it must be able to provide documentation for review by the FDA or other interested parties. In addition, the Joint Expert Committee on Food Additives (JECFA) also evaluates artificial flavors for their safety to humans. This international scientific committee is overseen by the Food and Agricultural Organization of the United Nations and the World Health Organization. The results of all of these assessments are contained in a massive database on the FDA’s website, titled “Substances Added to Food,” and found at https:// www.accessdata.fda.gov/scripts/fdcc/?set=FoodSubstances. Any consumer can search this database and click on the name of an ingredient to see its chemical composition and its purpose in food and then click on the substance’s GRAS numerical code to see the complete scientific analysis by FEMA committee or JECFA. Seven naturally occurring chemicals used as artificial flavors have been found to cause cancer in laboratory animals when consumed in large amounts. These were banned by the FDA in 2018 and are no longer in use as food additives in the United States, though some are still used to add scent to cosmetics and other products. They include benzophenone, which produces the floral smell in grapes and other fruits; ethyl acrylate, a fruity flavor found in pineapple; methyl eugenol, a spicy-tasting compound found in some essential oils; myrcene, which gives allspice its spicy pungency; pulegone, the minty compound found in peppermint and spearmint plants, orange mint, catnip, blackcurrant, and pennyroyal; pyridine, a sour flavor with a fishy smell, originally isolated in crude coal tar; and styrene, usually synthesized from plants in the Styrax genus, which also provides the naturally sweet taste in some fruits, vegetables, and nuts. The flavor industry, then, has worked to protect the public from substances that may indeed be harmful and inappropriate for human consumption. This has not stopped many organizations and people with their own agendas from working to demonize artificial flavors, however. NaturesHappiness.com (http:// blogs.natureshappiness.com/artificial-flavors-side-effects/), for example, insists that “studies suggest that the side effects of artificial flavorings range from nervous system depression, dizziness, chest pain, headaches, fatigue, allergies, brain

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damage, seizures, and nausea. Some of the most popular flavorings can also cause genetic defects, tumors and bladder cancer to name a few.” The blog’s agenda, of course, is to sell “natural” nutritional supplements, and the sources it provides for its information are within its own website. To be fair, some of the artificial flavors approved as GRAS have been found to be carcinogens at very high doses, but much higher than the amount a human being would consume. FEMA has considered such cases and determined that the substance is being used at a safe level, saying, “The results from animal studies are not relevant to human safety.” John Bloom, PhD, writing for the American Council on Science and Health, sums up this issue with clarity: When bad science is promoted, it is reasonable to assume that there are economic benefits to be gained by those who are behind the scare-mongering. . . . Thanks to marketing campaigns that are anti-science at their core, the American public has been conditioned to equate artificial flavoring with harmful chemicals. Consumers are bombarded by terms such as “organic,” “natural,” and “synthetic” wherever they shop, without having anything close to a clear definition of what each term means.

So these flavorings may be generally regarded as safe, but are they addictive? It is difficult to find a credible source on the subject, though there are thousands of blogs and websites written by nonscientists who decry these substances and their use to manipulate the taste buds. Harvard University’s website contains an essay by PhD candidate C. Rose Kennedy of the Department of Chemistry and Chemical Biology, in which she notes, Flavors are used to amplify or modulate the sensory experience associated with existing qualities of a product. Furthermore, they may also be used to make healthy yet bland options (like those lacking an excess of sugar or trans-fat) more appealing. For example, flavor agents may make reduced-fat foods seem rich and creamy, or add salty zest to low-sodium products.

Artificial flavors contain no components that form a physical addiction, but they may promote cravings for more of the flavored food. A number of professional flavorists quoted in media reports ranging from the New York Times to the CBS news show 60 Minutes describe an intention to create a powerful burst of flavor that quickly fades, making the consumer want more. Artificial flavors may also be used to intensify a flavor beyond its natural counterpart—such as a robust, sweet flavor of a raspberry candy versus the taste of an actual raspberry. Some bloggers suggest that this creates an unrealistic expectation of the flavor of real fruit in children who eat candy, but this may bring up a larger question of the availability of fresh fruit to a child—or of a parent’s own choices—rather than an intentional deception by the candy maker.

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FURTHER READINGS “About FEMA GRAS Program.” Flavor & Extract Manufacturers Association, 2018. Accessed July 24, 2019. https://www.femaflavor.org/gras “Benzophenone.” Chemical safetyfacts.org. Accessed July 24, 2019. https://www.chemical safetyfacts.org/benzophenone/ Bloom, Josh. “Natural and Artificial Flavors: What’s the Difference?” American Council on Science and Health, New York, 2017, 29. Accessed July 24, 2019. https://www.acsh .org/sites/default/files/Natural-and-Artificial-Flavors-What-s-the-Difference.pdf “CFR: Code of Federal Regulations, Title 21, Sec. 101.22.” U.S. Food and Drug Administration, revised Apr. 1, 2018. Accessed July 17, 2019. https://www.accessdata.fda.gov /scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=101.22 “Chemical Cuisine.” Center for Science in the Public Interest. Accessed July 24, 2019. https://cspinet.org/eating-healthy/chemical-cuisine#banned “Ethyl acrylate.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/Ethyl -acrylate Kennedy, C. Rose. “The Flavor Rundown: Natural vs. Artificial Flavors.” Science in the News, Harvard University Graduate School of Arts and Sciences, Sept. 21, 2015. Accessed July 24, 2019. http://sitn.hms.harvard.edu/flash/2015/the-flavor-rundown -natural-vs-artificial-flavors/ “Methyleugenol.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/7127 “Myrcene.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/31253 “Pulegone.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/442495 “Pyridine.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/1049 Reineccius, Gary. “What Is the Difference Between Artificial and Natural Flavors?” Scientific American, July 29, 2002. Accessed July 17, 2019. https://www.scientificamerican .com/article/what-is-the-difference-be-2002-07-29/ Stokes, Abbey. “Understanding How Natural and Artificial Flavors Impact Food Product Naming.” Merieux NutriSciences, May 31, 2018. Accessed July 17, 2019. http://foodsafety.merieuxnutrisciences.com/2018/05/31/understanding-how-natural -artificial-flavors-impact-food-product-naming/ “Styrene.” PubChem, U.S. National Library of Medicine, National Institutes of Health. Accessed July 24, 2019. https://pubchem.ncbi.nlm.nih.gov/compound/7501 “Substances Added to Food.” U.S. Food and Drug Administration, last updated Apr. 22, 2019. Accessed July 24, 2019. https://www.accessdata.fda.gov/scripts/fdcc/?set=Food Substances Wendee, Nicole. “Secret Ingredients: Who Knows What’s in Your Food?” Environmental Health Perspectives, Apr. 2013, 121(4), a126–a133. Accessed July 24, 2019. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3620743/

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Artificial Food Colors WHAT ARE THEY? Artificial food colors (AFCs), also known as food dyes, are colors made from chemicals or from natural substances and are used to improve or enhance the appearance of foods to make them more appetizing. A wide variety of substances have been used to make these dyes, but today’s dyes are largely petroleum based. Only nine AFCs are currently approved as safe by the U.S. FDA for use in food. Many others have turned out to be toxic and have been banned. Each dye is approved for use with a specific food or foods; to expand to additional uses, the dye must be reapproved by the FDA as an additive for that food. Red No. 40, for example, can be used in cereals, gelatins, dairy products, puddings, beverages, and confections, while Orange B has only received approval for use in hot dog and sausage casings. The FDA tests and certifies each individual batch of approved food color for purity and safety before it can be used in any foods.

CURRENT CONSUMPTION STATISTICS AND TRENDS Red Dye 40 (Allura Red), Yellow No. 5 (Tartrazine), and Yellow No. 6 (Sunset Yellow) make up 90 percent of the food dyes used in the United States. Six other dyes, including additional shades of red, yellow, orange, green, and blue, complete the fairly narrow assortment of dyes used in packaged products. Breakfast cereals, vitamin pills, candy, beverages, snacks, and other edibles often contain these dyes, especially products with children as their primary targets. They are also used to “correct” the colors of natural products, such as fruit, cheese, and packaged meat. Ameena Batada at the University of North Carolina and Michael F. Jacobson at the Center for Science in the Public Interest completed a study in 2014 in which they examined 810 products purchased in a North Carolina grocery store. All of the products they chose were marketed heavily to children. The researchers found that 350 of these products contained artificial food dyes: Nearly 30 percent had Red 40; 24.2 percent contained Blue 1; 20.5 percent contained Yellow 5; and 19.5 percent used Yellow 6. Candy had the highest percentage of food dyes (96.3 percent), while 94 percent of fruit-flavored snacks were artificially colored. Not surprisingly, 89.7 percent of drink mix powders were colored with food dyes. In 2014, a study by Laura Stevens et al. determined that children, on average, consume 100–200 mg of AFCs per day.

NUTRITIONAL INFORMATION AFCs provide no vitamins, minerals, or other nutritional value to the foods they color. They add no calories to food.

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HISTORY The first records of coloring foods with natural dyes came from Egypt in 1500 BC, but controversy didn’t emerge in the coloring process until the late 1200s, under England’s King Edward I. Wealthy people of the time preferred white flour and white bread to the darker breads made for peasants, but the common people became dissatisfied with their lower-class bread and demanded a white bread alternative that they could afford. Bakeries complied by using inexpensive alternative ingredients to lighten the bread—like lime and chalk instead of white flour. This, of course, made the bread less palatable and made those who ate it quite ill. The London government took action, making the first known law against food adulteration: If any default shall be found in the bread of a baker in the city, the first, time, let him be drawn upon a hurdle from the Guildhall to his own house through the great street where there be most people assembled, and through the streets which are most dirty, with the faulty loof [sic] hanging from his neck.

A second offense got the baker a session of verbal and physical abuse on the pillory, and if, after all of this punishment, the baker still persisted in coloring bread with dangerous substances, he or she would be forbidden from baking forever. Additional laws came to pass over the next several hundred years, with a French bill forbidding the coloring of butter in 1396 and another in 1574 that prohibited bakers from using food dyes to color pastries so they looked as if eggs were used in their preparation. The first mass-market exposure of the dangers of many substances used to color food came in 1820, with the publication of A Treatise on Adulterations of Food and Culinary Poisons, by Friedrich Accum, an English chemist. Among the many abuses he detailed, Accum noted that pickles often were colored with copper so they would appear bright green; bakers continued to color bread white, but now used metallic salts also used in styptic pencils to stanch bleeding; and candy manufacturers used mercury, lead, and dyes that contained copper and even arsenic to achieve the bright colors that attracted children to buy them. In 1856, Sir William Henry Perkin of England used aniline, an organic compound synthesized from coal tar, to develop new food dyes that were somewhat safer than the dyes made from metal salts. Coal-tar dyes produced brighter colors, but required the use of a tiny fraction of the amount of more harmful food dyes to achieve the desired color. Denmark and Germany both passed laws in the 1850s to ban the use of colors that contained harmful chemicals. England finally followed suit in 1860 with the Food Adulteration Act, but real change did not come until the Sale of Food and Drugs Act of 1875, which made the use of harmful chemicals in food a criminal offense. Laws in the United States did not catch up with the toxic colorants issue for some time. The government began looking into the problem in 1881, but it took until the Pure Food and Drug Act of 1906, the first consumer protection law, for

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Congress to ban the use of colored metal salts and other harmful substances in food. This law’s requirements only covered food and drugs sold across state lines, however, and it focused primarily on preservatives and on truth in food labeling. Before the law, one food coloring battle became legendary in the history of additives. Margarine entered the market in the late 1800s, spurring the dairy industry to look for ways to keep this butter replacement out of stores or at least to make it unappetizing to consumers. Claims by a dairy publicity campaign that margarine actually carried cancer “germs” and was made from soap, paint, animal intestines, and even old boots made a definite impression on consumers, leading seven states to ban margarine altogether. The Supreme Court overturned these laws as restraint of trade, so the dairy industry tried another tack: They attacked margarine’s color, saying that white margarine could not possibly compete with the naturally hued golden-yellow butter. States banned the manufacture of margarine that was artificially colored yellow, saying that the color only served to deceive the public into thinking it was really butter. Eventually Congress took a nationwide step, levying a margarine tax and licensing fee that made yellow margarine more expensive to consumers than real butter. In the decades-long battle that ensued, margarine manufacturers tried to get around the tax by actually selling white margarine with packets of yellow dye enclosed, so consumers could mix in the color themselves. Realizing the ludicrousness of this, Congress finally repealed its tax in 1950 and included specific, less restrictive rules about margarine color in the Federal Food, Drug, and Cosmetic Act in the same year. In 1967, the last law against coloring margarine—not surprisingly, in the dairy state of Wisconsin—was finally repealed. The next food dye scandal came in the 1960s, when studies began to indicate that red dye 2 might be carcinogenic. The FDA placed the dye on its provisional list until the science could be sorted out, but additional studies yielded inconsistent results, including a large Russian effort that may not even have tested the right dye. Finally, the FDA conducted its own study, which turned out to be even less dependable than the Russian one—in fact, it earned the permanent moniker “the botched FDA experiment.” Whether the dye actually causes more cancerous tumors in rats, and whether this result translates to human beings, has never been proven conclusively. Amidst considerable controversy, however, the FDA took the step to delist red dye 2 from its approved AFCs in 1976, putting an end to the discussion. Today’s AFC formulations use petroleum instead of coal, assuaging some fears that the dyes were actively toxic. Not all manufacturers rely on chemicals to color their products, however. Some have turned to natural food coloring agents, including carotenoids (the bright orange of carrots), chlorophyll (which gives all green plants their color), anthocyanin (the blue and purple of blueberries, grapes, and cranberries), turmeric (the yellow of mustards), and cochineal (a brilliant red derived from insects). These dyes are costly to produce, however, as they require growing and harvesting plants in season and considerable effort to process the material and extract the colors. They also spoil quickly, making their shelf life

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very short for the amount of trouble they are to make. Worse, cochineal dye triggers a severe allergic reaction in some people, including anaphylactic shock. Some natural colors may actually have nutritive value, however, making them preferable as the market demands that food be free of artificial additives and that food producers maximize the health benefits of their products.

THE CONTROVERSY The question of whether AFCs and other food additives have an effect on attention-deficit/hyperactivity disorder (ADHD)—or even cause the disorder— has kept researchers busy for generations dating back to the 1920s. The first to draw a direct connection between ADHD and AFCs was pediatric allergist Benjamin Feingold, who reported in 1973 that his research showed a link between hyperactivity and an assortment of food additives, including salicylates, artificial colors, artificial flavors, and preservatives BHA and BHT. He designed a diet free of these added chemicals, which became known as the Kaiser Permanante diet and later as the Feingold diet. His two books, Why Your Child Is Hyperactive and The Feingold Cookbook for Hyperactive Children, became national bestsellers . . . but by 1983, other researchers examined his findings and essentially negated the diet’s effectiveness in treating children with ADHD. Many more studies followed, but for purposes of this discussion, let’s jump ahead to 2004, when David W. Schab and Nhi-Ha T. Trinh gathered fifteen double-blind placebo-controlled studies conducted to that date and performed a comprehensive, quantitative meta-analysis in an attempt to draw meaningful conclusions. This was the first meta-analysis on the subject of food colors since K.A. Kavale and S.R. Forness performed theirs in 1983, so it included many studies that had been completed in the ensuing twenty years. The results of this work “strongly suggest an association between ingestion of AFCs and hyperactivity,” their conclusion states, but the researchers called for additional studies to fill in the blanks in the global understanding of this effect. We recommend that future research avoid the pitfalls of many prior trials by explicitly identifying subjects’ demographic characteristics; by employing specific diagnostic criteria and by identifying diagnostic subtypes and comorbidities; by identifying the concurrent use of medications; by specifying the interval between administration of AFCs and measurement of effect; by administering specific AFCs rather than mixtures; by explicitly testing the blinding of subjects; and by reporting all such information in published reports.

In a paper published in 2011, Joel T. Nigg et al. completed another metaanalysis of recent studies and determined that some children with ADHD benefit from restricting food additives including colors: “Effects of food colors were notable but susceptible to publication bias or were derived from small, nongeneralizable samples. Renewed investigation of diet and ADHD is warranted.”

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In 2013, after a wide range of laboratory testing on rats and mice had taken place on all nine of the FDA-approved food dyes, Kobylewski and Jacobson called for still more testing on humans to determine if the reactions found in rodents also take place in human beings. In their study, published in 2013 in the International Journal of Occupational and Environmental Health, they reviewed all of the studies to that date and concluded that each had provided enough warning signs about potential harm to alert the food industry that these additives could be dangerous. “The inadequacy of much of the testing and the evidence for carcinogenicity, genotoxicity, and hypersensitivity, coupled with the fact that dyes do not improve the safety or nutritional quality of foods, indicates that all of the currently used dyes should be removed from the food supply and replaced, if at all, by safer colorings,” they wrote. As recently as 2018, the American Academy of Pediatrics advised that AFCs “may be associated with exacerbation of ADHD symptoms,” but even this statement of official policy is couched in indefinite language. The medical and research communities, AFC manufacturers, and the FDA remain on the fence about whether or not these additives may be detrimental to children’s health.

FURTHER READINGS Arnold, L. Eugene; Lofthouse, Nicholas; and Hurt, Elizabeth. “Artificial Food Colors and Attention Deficit/Hyperactivity Symptoms: Conclusions to Dye For.” Neurotherapeutics, July 2012, 9(3), 599–609. Accessed Jan. 25, 2020. https://www.ncbi.nlm.nih.gov /pmc/articles/PMC3441937/#__ffn_sectitle Batada, Ameena; and Jacobson, Michael F. “Prevalence of Artificial Food Colors in Grocery Store Products Marketed to Children.” Clinical Pediatrics, June 6, 2016. Accessed Jan. 24, 2020. https://journals.sagepub.com/doi/abs/10.1177/0009922816651621?journal Code=cpja& Burrows, Adam. “Palette of Our Palates: A Brief History of Food Coloring and Its Regulation.” Comprehensive Reviews in Food Science and Food Safety, Sept. 16, 2009. Accessed Jan. 28, 2020. https://doi.org/10.1111/j.1541-4337.2009.00089.x “Color Additives Questions and Answers for Consumers.” U.S. Food and Drug Administration, Jan. 4, 2018. Accessed Jan. 24, 2020. https://www.fda.gov/food/food-additives -petitions/color-additives-questions-and-answers-consumers Kavale, K.A.; and Forness, S.R. “Hyperactivity and Diet Treatment: A Meta-analysis of the Feingold Hypothesis.” Journal of Learning Disabilities, 1983, 16(6), 324–330. Kobylewski, Sarah; and Jacobson, Michael. “Food Dyes: A Rainbow of Risks.” Center for Science in the Public Interest, 2010. Accessed Jan. 24, 2020. https://cspinet.org/sites /default/files/attachment/food-dyes-rainbow-of-risks.pdf Kobylewski, Sarah; and Jacobson, Michael. “Toxicology of Food Dyes.” International Journal of Occupational and Environmental Health, Nov. 12, 2013. Accessed Jan. 24, 2020. https://www.tandfonline.com/doi/abs/10.1179/1077352512Z.00000000034 Nigg, Joel T., et al. “Meta-Analysis of Attention-Deficit/Hyperactivity Disorder or Attention-Deficit/Hyperactivity Disorder Symptoms, Restriction Diet, and Synthetic Food Color Additives.” Journal of the American Academy of Child and Adolescent

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Psychiatry, Jan. 2012, 51(1), 86–97. Accessed Jan. 25, 2020. https://www.sciencedirect .com/science/article/abs/pii/S0890856711009531 Rohrig, Brian. “Eating With Your Eyes: The Chemistry of Food Colorings.” Chem Matters Online, American Chemical Society, Oct. 2015. Accessed Jan. 25, 2020. https:// www.acs.org/content/acs/en/education/resources/highschool/chemmatters/past -issues/2015-2016/october-2015/food-colorings.html Schab, David W.; and Trinh, Nhi-Ha T. “Do Artificial Food Colors Promote Hyperactivity in Children with Hyperactive Syndromes? A Meta-Analysis of Double-Blind Placebo-Controlled Trials.” Journal of Developmental and Behavioral Pediatrics, Dec. 2004, 25(6), 423–434. Accessed Jan. 24, 2020. https://journals.lww.com/jrnldbp/full text/2004/12000/do_artificial_food_colors_promote_hyperactivity_in.7.aspx?casa_tok en=NdciYj1IZrEAAAAA:yAFAg3v8KGyVSBIBHHq5buGJ2tQJyRXWrjUm7n6 jB67MzbQ379I_rpV9z5-t_TQQlJ4u8_0AJeXo67_fVaGjL9Ub Stevens, Laura, et al. “Amounts of Artificial Food Dyes and Added Sugars in Foods and Sweets Commonly Consumed By Children.” Clinical Pediatrics, Apr. 24, 2014, 54(4), 309–321. Accessed Jan. 25, 2020. https://journals.sagepub.com/doi/abs/10.1 177/0009922814530803?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr _id=ori%3Arid%3Acrossref.org&journalCode=cpja Trasande, Leonardo, et al. “Food Additives and Child Health.” Pediatrics, Aug. 2018, 142(2). Accessed Jan. 25, 2020. https://pediatrics.aappublications.org/content/142/2 /e20181408

Artificial Sweeteners WHAT ARE THEY? Artificial sweeteners add sweetness to foods without adding calories or by adding a tiny fraction of the calories of sugar. Also known as nonnutritive sweeteners or sugar substitutes, the six artificial sweeteners listed by the FDA as “GRAS” include aspartame (Equal®, SugarTwin®, or NutraSweet®, packaged in blue packets), sucralose (Splenda®, packaged in yellow), and saccharin (Sweet’N Low®, SweetTwin®, or NectaSweet®, in pink packets), as well as sweeteners used primarily in packaged foods: acesulfame-potassium (Ace-K, also known as Sunett® or Sweet One®), a sweetener with a bitter aftertaste that is often combined with another artificial sweetener in food processing; neotame (Newtame®), an intense sweetener manufactured by NutraSweet, said to be fifteen times sweeter than Splenda and up to 8,000 times sweeter than sugar; and advantame, which is 20,000 times sweeter than table sugar. Some sources also include steviol glycosides (Stevia®, green packets) as an artificial sweetener, as it occurs naturally in the leaves of the Stevia rebaudiana plant, but is often extracted using chemicals, particularly ethanol. The FDA lists steviol glycosides as a high-intensity sweetener (200–400 times sweeter than

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sugar) and considers the high-purity stevia-derived sweeteners (95 percent minimum purity) as GRAS, but stevia leaf and crude stevia extracts do not quality as GRAS and are “not permitted for use as sweeteners.”

CURRENT CONSUMPTION STATISTICS AND TRENDS The most recent scholarly study on consumption of artificial sweeteners comes from the Milken Institute School of Public Health at George Washington University, published in January 2017. The study determined that in 2012, roughly 25 percent of children in the United States and more than 41 percent of adults say that they consume foods that contain “low-calorie sweeteners,” as the report calls them, including aspartame, sucralose, and saccharin. This is a significant increase over 1999, when just 8.7 percent of children and about 20 percent of adults reported choosing artificial sweeteners over sugar. The study goes on to note that 44 percent of adults and 20 percent of children surveyed said that they ate or drank products with artificial sweeteners in them more than once a day—and 17 percent of adults said they had an artificially sweetened beverage three or more times a day. “The likelihood of consuming low-calorie sweeteners went up as adult body mass index, a measure of obesity, went up,” a summary of the study said. “Nineteen percent of adults with obesity compared to 13 percent of normal weight adults used [low-calorie sweetened] products three times a day or more.”

NUTRITIONAL INFORMATION Sugar adds 16 calories per teaspoon to foods and drinks, and a 12-ounce canned soft drink that contains 39 g of sugar (usually in the form of high-fructose corn syrup, which is even more concentrated than sugar) adds about 160 calories to a meal or snack. Saccharin, sucralose, and aspartame are noncaloric and pass through the body without metabolizing, so they add no calories or carbohydrates to foods or drinks. They also gained the moniker “high-intensity sweeteners,” because they are many times sweeter than sugar. Sucralose, for example, is 600 times sweeter than sugar, while stevia beats sugar’s sweetness by 200–400 times. Saccharin is 300–500 times sweeter than sugar, and aspartame exceeds sugar’s sweetness by 160–200 times. This means that foods and drinks require very small amounts of these sweeteners to achieve the desired sweetness—which is why a single-serving packet of sugar contains about a teaspoon (2–4 g), while a packet of Splenda contains just 12 mg of sucralose, or less than 1/100 of a teaspoon. While artificial sweeteners have no nutritive value of their own, they are not carbohydrates, so their use can reduce the negative effects on the body of eating foods sweetened with sugar. Excessive sugar consumption causes weight gain, increases overall blood sugar levels beyond what is needed to produce energy, and can lead to obesity-related diseases including heart disease and diabetes. Artificial sweeteners do not have these effects.

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HISTORY The concept of artificial sweeteners had not risen to the scientific consciousness before 1879, when Constantine Fahlberg, a researcher at Johns Hopkins University, stumbled upon one by accident. He worked in professor Ira Remsen’s laboratory and, in the midst of an experiment, spilled a chemical—a coal-tar derivative—on his hands. The very model of the absent-minded scientist, he forgot about the spill and neglected to wash his hands before dinner, and paused in mid-bite when something on his hands made the bread taste sweet. Most people might have seen this swallowing of an unknown substance as a potential threat to life and limb, but Fahlberg reacted with scientific curiosity. He returned to the lab, tasted every chemical he had used that day—again, with no regard for the very likely event that at least one may have been poisonous—and finally sipped from a beaker filled with benzoic sulfimide, which tasted sweeter than sugar. He and Remsen wrote a paper together listing them both as the creators of the new compound. In 1884, Fahlberg obtained a patent for the process that created the sweetener, which he had named saccharin, and began seeing commercial success with the new product. He essentially cut Remsen out of the business, however, leading Remsen to comment in a letter to another chemist, William Ramsey, “Fahlberg is a scoundrel. It nauseates me to hear my name mentioned in the same breath with him.” Saccharin saw some early interest, especially after Fahlberg produced the results of thousands of tests that proved it was not toxic, but the sugar beet lobby soon recognized it as a threat to Central European farmers’ livelihoods. It campaigned heavily against the new substance and actually succeeded in restricting saccharin’s use to pharmaceuticals, effectively ending the growth of the artificial sweeteners industry in the short term. Undaunted and well aware of the potential usefulness of his product, Fahlberg toughed out the ban until the beginning of World War I, when attitudes toward saccharin changed. In the face of sugar shortages throughout the United States and Europe, saccharin became a relatively inexpensive way to keep sweetened packaged foods on the market. Central European governments lifted the ban on its use in food, and saccharin became a massively successful product—much to Remsen’s continued chagrin, though he refused an offer from pharmaceutical manufacturer Merck & Company to challenge Fahlberg’s patent. Remsen’s response: He “would not sully his hands with industry” (Allen & O’Shea, p. 161). Such a popular and lucrative product could not exist as the only artificial sweetener for long. In the 1950s, sodium cyclamate—the sweetener known simply as cyclamates—arrived on the market and soon became the preferred brand for many uses, especially soft drinks. While saccharin could produce a bitter aftertaste that reminded the consumer that it was not real sugar, cyclamates had no bitterness, so it gained popularity rapidly. With increased consumption of diet drinks and snacks sweetened with the new substance, however, came an accompanying

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increase in bladder cancer, particularly in men. Scientists began testing cyclamates and discovered that rats in a laboratory setting developed bladder cancer when they ate large doses of the chemical. The FDA moved quickly to order all foods and drinks containing cyclamates to be removed gradually from the market, beginning in the fall of 1969. . . but the FDA allowed some use of cyclamates in diet foods made specifically for diabetics, because the organization believed that the risk of cancer was less dangerous than the risk of obesity in these patients. In 1970, it reversed this position and took cyclamates off the market altogether. This launched a decade of more careful scrutiny of saccharin, leading to studies that seemed to point to the sweetener as another cause of bladder cancer in rodents. In 1981, saccharin was placed on the U.S. National Toxicology Program’s Report on Carcinogens list, which resulted in the requirement that the makers of the artificial sweetener print a warning on any package containing saccharin, stating that this product might cause cancer. Further studies determined, however, that saccharin only causes cancer in rats, through a mechanism not found in the human body. Testing involving human subjects showed no relationship between saccharin and bladder cancer, so the sweetener came off the carcinogens list in 2000. Aspartame entered the market in 1981, when the FDA completed its review of tests that showed that it did not cause cancer. Sucralose received its FDA approval for general use in 1998, and it was followed by acesulfame-potassium and neotame in 2002 and advantame in 2014.

THE CONTROVERSY The scientific community has struggled to reach any kind of consensus on the health benefits versus the hazards of using artificial sweeteners in foods and drinks. Studies have produced a wide range of positive and negative results, and while claims that artificial sweeteners are carcinogens have been largely put to rest, scientists tirelessly pursue the answer to whether any or all of these sweeteners are harming the human body in other ways. Perhaps scientists believe that the idea that something that tastes so good can also improve our health is simply too good to be true, but some studies point to potentially negative effects of these sweeteners—and other studies indicate that they have no adverse effects at all. The more salient argument is whether or not artificial sweeteners assist with weight loss. The short answer appears to be no, especially in the category of diet drinks. People who drink diet soda, for example, often make the decision to eat foods that more than make up for the calories they saved with the diet drink— for example, “I was good and ordered a diet drink, so now I can have ice cream.” Some studies have suggested that the artificial sweeteners themselves cause people to gain weight, including a 2005 study conducted by the University of Texas Health Science Center at San Antonio, in which the researchers concluded that

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people who drank diet soda gained more weight than people who drank soda sweetened with sugar or corn syrup (DeNoon). An even more troubling finding by S.E. Swithers and T.L. Davidson at Purdue University revealed that humans and animals use sweetness to tell them that a food is highly caloric, so that the body can gauge how much food it needs to maintain its energy. Sweet foods that contain fewer calories appear to deceive the body’s energy regulation system (sugar digestion, involving insulin), so the body craves additional calories and continues to eat. This phenomenon leads to increased weight gain from eating much more of an artificially sweetened food than a person may have eaten of a food containing sugar. “A sweet taste induces an insulin response, which causes blood sugar to be stored in tissue,” wrote Kirtida R. Tandel succinctly in a literature review in the Journal of Pharmacology & Pharmacotherapeutics in October 2011, “but because blood sugar does not increase with artificial sweeteners, there is hypoglycemia and increased food intake.” Hundreds of studies have contributed to this controversy, but many of these do not meet the standards for scientific rigor to become definitive on the subject. Studies involving mice or rats and their sweetener intake may not be relevant to human experience, as rodents digest and use sugar differently from people. Studies with a handful of subjects and few controls cannot be considered conclusive; at best, they serve as potential models for much more substantial research. Literature reviews struggle to draw conclusions because of the sheer volume of studies to review and categorize. One recent study stands out from the rest, however. It appeared in the September 2019 issue of JAMA Internal Medicine, one of the peer-reviewed journals of the American Medical Association. The study uses the availability of massive amounts of data from the European Investigation into Cancer and Nutrition to review the soft drink consumption habits of 451,743 people in ten European countries, gathered from 1992 to 2000. Lengthy analysis of the data determined that people who consumed two or more soft drinks a day—sweetened with sugar or artificial sweeteners—had “higher all-cause mortality.” This means that people who habitually drank soft drinks on a daily basis died during the study more frequently than people who drank less than one glass of a soft drink per month (Mullee et al.). The study went on to break down the causes of death, based on whether the participants reported that they drank sugar-sweetened soft drinks or artificially sweetened ones. People who drank two or more diet soft drinks a day were more likely to die from a circulatory disease (stroke or heart disease), while people who drank sugary drinks died more often from digestive diseases (diabetes, kidney and liver diseases, and colorectal cancer). “Total soft drink consumption was positively associated with colorectal cancer deaths,” the study said, but they could not find a correlation between soft drinks and breast or prostate cancer. “We observed no association between soft drink consumption and overall cancer mortality,” the authors continued. “This result is consistent with findings in most

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previous studies, which found little evidence of a direct association between soft drink consumption and cancer risk.” In addition, this may be the first study to report a correlation between total soft drink consumption and a greater risk of death from Parkinson’s disease. The risk is present for people who drink either sugar-sweetened or diet soft drink quantities of two per day or more. The study stops short of suggesting that the soft drinks actually cause the diseases and only states that it found “positive associations” between the drinks and the diseases people developed. “Further studies are needed to investigate the possible adverse health effects of artificial sweeteners,” it concludes. So there continues to be no definitive answer on whether artificial sweeteners assist in weight loss or even if they trigger a glycemic response in the human body. What we do know is that the FDA considers them safe for consumption—but, like all foods, only in moderation.

FURTHER READINGS Allen, Thomas J.; and O’Shea, Rory P. Building Technology Transfer Within Research Universities. Cambridge, England: Cambridge University Press, 2014, p. 159–161. “Artificial Sweeteners and Cancer.” National Cancer Institute, National Institutes of Health. Accessed Aug. 22, 2019. https://www.cancer.gov/about-cancer/causes -prevention/risk/diet/artificial-sweeteners-fact-sheet “Consumption of Low-Calorie Sweeteners Jumps by 200 Percent in U.S. Children.” George Washington University, Milken Institute School of Public Health, Jan. 10, 2017. Accessed Aug. 19, 2019. https://publichealth.gwu.edu/content/consumption -low-calorie-sweeteners-jumps-200-percent-us-children DeNoon, Daniel J. “Drink More Diet Soda, Gain More Weight? Overweight Risk Soars 41% with Each Daily Can of Diet Soft Drink.” WebMD Medical News, 2005. “Healthy Lifestyle: Nutrition and Healthy Eating.” Mayo Clinic. Accessed Aug. 21, 2019. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth /artificial-sweeteners/art-20046936 Lyons, Richard D. “The FDA Orders a Total Cyclamate Ban.” New York Times, Aug. 23, 1970, p. E6. Accessed Aug. 22, 2019. https://www.nytimes.com/1970/08/23/archives /the-fda-orders-a-total-cyclamate-ban-another-switch.html Mullee, Amy, et al. “Association Between Soft Drink Consumption and Mortality in 10 European Countries.” JAMA Internal Medicine, Sept. 3, 2019. Accessed Sept. 9, 2019. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2749350 ?guestAccessKey=b99410a9-8afc-4953-b328-bbb2620dfacd&utm_source=For_The _Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm _term=090319 Swithers, S.E.; and Davidson, T.L. “A Role for Sweet Taste: Calorie Predictive Relations in Energy Regulation by Rate.” Behavioral Neuroscience, Feb. 2008, 122(1), 161–173. Accessed Aug. 22, 2019. https://www.ncbi.nlm.nih.gov/pubmed/18298259/ Tandel, Kirtida R. “Sugar Substitutes: Health Controversy Over Perceived Benefits.” Journal of Pharmacology & Pharmacotherapeutics, Oct. 2011, 2(4), 236–243. Accessed Aug. 22, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198517/

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Bottled Water WHAT IS IT? Water in a bottle seems like the simplest product to define, but it comes from a wide range of sources and therefore requires a fairly complex set of definitions. The FDA regulates bottled water, so consumers may see a number of different classifications based on each brand’s origin and additional contents. • Alkaline water contains a higher level of pH than standard drinking water, which in itself has no specific benefit; but it also has negative oxidation reduction potential. This means that it acts as an antioxidant, which may make it slightly beneficial for certain health issues, including acid reflux. The potential benefits also depend on whether the water gained its alkalinity naturally (by flowing over rocks and picking up minerals) or chemically (via electrolysis in a bottling plant). • Artesian water is spring water trapped under the surface by hard rock, so it cannot break through on its own. Humans gain access to it by digging a well. The water flows between rocks underground at high natural pressure, a process that acts as a natural filter. (Spring water lives underground as well, but a spring finds its way to the surface without human assistance.) • Distilled water has been purified by boiling it into vapor and then condensing it back into liquid. This removes impurities, making the water safe for specific uses, like in medical equipment or appliances (e.g., use in a steam iron or CPAP machine). • Ionized water has been treated with a device called an ionizer to raise its pH level, separating acidic and alkaline molecules and removing the acidic ones. This is one way to achieve the higher pH of alkaline water, which may be slightly beneficial to people with chronic acid reflux. • Mineral water must be bottled at its source—natural reservoirs and mineral springs. It contains a regulated amount of dissolved minerals—more than 250 parts per million in the United States. It may contain bicarbonate, calcium, iron, magnesium, potassium, sodium, and/or zinc, and it may be processed to remove potential toxins like arsenic that it came by naturally. Sometimes carbon dioxide has been removed from it as well—and sometimes it is added to produce carbonation. • Purified water (or demineralized water) has had impurities removed via distillation, reverse osmosis, or deionization. Many purified water suppliers use tap water to fill their bottles, purifying it to remove the unpleasant-tasting chemicals often required to treat water in municipal water systems. • Sparkling water (seltzer) contains carbon dioxide that creates carbonation (bubbles). This may be plain or flavored slightly with trace amounts of fruit—more to activate the sense of smell than taste. The popular sparkling waters on the market now are zerocalorie products that contain nothing but carbonated water and scent. Some sparkling water products offer stronger fruit flavors, mixed with some kind of sweetener; most recently, “hard” seltzer spiked with alcohol has joined the water market. • Spring water must come from a flowing source that begins underground and finds its own way to the planet’s surface.

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• Vitamin water (fortified or enriched water) is water to which vitamins and minerals have been added. It often contains artificial sweetener or some form of sugar (fructose, corn syrup, or cane sugar) as well as colors and flavors added by the manufacturer. Some brands have as much sugar in them as a similarly sized can of regular cola. Soft drinks masquerading as health boosters, enriched water brands contain enough nonnutritive additives to make them a poor choice for regular hydration. • Well water comes from a human-made well, which in turn gets its water from an underground aquifer.

CURRENT CONSUMPTION STATISTICS AND TRENDS In the United States in 2017, Americans consumed 42.1 gallons of bottled water per person. If we break that down by standard 16.9-ounce bottles, that averages out to a little more than 159 bottles each or a bottle every 2.2 days. Beverage Industry magazine reported in July 2019 on a poll taken by the International Bottled Water Association earlier that year, which discovered that bottled water is the number one drink among consumers. Bottled water sales show no sign of slowing—in fact, the market continues to grow. A remarkable 72 percent of Americans said that bottled water is their preferred nonalcoholic beverage, up 9 percent from the previous year. Still water alone (as opposed to sparkling), sold in single serving bottles or as jugs for water coolers, represents a nearly $14 billion market, with the greatest share going to private label brands—store brands that are usually bottled by the big name brands, labeled for local supermarkets, and sold at lower prices than the name brands. Sparkling water adds another $3 billion to the market’s total. What is driving this juggernaut? Consumers clearly want alternatives to sweetened soft drinks like soda and juices, especially when presented with the harmful effects of high-fructose corn syrup, one of the most popular sweeteners in processed foods and drinks. At the same time, flavored waters have gained traction, including those with as much sweetener and flavoring in them as a 12-ounce can of cola.

NUTRITIONAL INFORMATION For the most part, bottled water has no calories, and its nutritional value lies in hydration rather than in the trace amounts of calcium, sodium, or other minerals that may be found in water at the source or that may remain after filtering. Water is vital to the proper functioning of every part of the human body. It aids the bloodstream in carrying nutrients to cells, assists in digestion, prevents constipation, balances the body’s electrolytes, protects organs, provides the basis for urine to flush out the bladder, and even regulates body temperature. Whether water comes from the tap or from a bottle, it provides all of these benefits—and tap water does these things just as well as bottled water. The exception may be mineral water, which can be a source of calcium, magnesium, and potassium, things the body needs on a regular basis. Studies have

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shown that drinking mineral water can increase the body’s levels of these minerals, which can in turn help build stronger bones, lower blood pressure, and regulate circulation and heartbeat. It may also have a relieving effect on constipation. Some water products contain a number of additives that contribute vitamins to the body’s intake. Some of these also contain flavorings, fruit juices, and sugar or sugar alcohols, which add calories. The value of the added vitamins—which are readily available in foods most people eat anyway—may be negated by the effects of the added sugar, a central component in weight gain, diabetes, and heart disease. Consumers should be careful to read the labels on these products and check the carbohydrate load to be certain that they are choosing a water product without sugar.

HISTORY People have carried water in containers since the Roman empire and probably before that, but bottled water first became a marketable product in the United Kingdom in 1622, when the Holy Well bottling plant sold water from its mineral springs. Seeing the success of this first enterprise, other locations with mineral springs followed suit, making the water industry a new enterprise by the beginning of the 1700s. The concept came to the United States as far back as 1767, when Jackson’s Spa in Boston packaged its natural spring water for sale, with the altruistic-sounding goal of sharing its supposed medicinal properties with a wider audience. In 1783, Swiss entrepreneur Johann Jacob Schweppe found a way to carbonate water, a quality that had been restricted to natural mineral springs. American businessman Joseph Hawkins discovered the carbonation method around the same time and on his own, securing the U.S. patent for the carbonation process in 1809 and marketing bubbly water across the country. By 1856, bottled water had become a significant industry, with more than seven million bottles sold by Saratoga Springs in New York State, another spa area with natural springs believed to have healing ability. As cholera and typhoid swept through the country’s cities, many people turned to bottled water as a safe way to obtain drinking water. It took until 1908 for scientists to determine that disinfection of municipal water supplies with chlorine could prevent the spread of disease. Jersey City, New Jersey, became the first city to disinfect its drinking water with chlorine, and its success led every other major water supplier to do the same, which stymied the bottled water market. With the introduction of plastic bottling for carbonated beverages in 1973, bottled water had a chance to emerge once again. The first brand to take full advantage of this was Perrier, introduced in the United States in 1977, bringing carbonated water back to the marketing forefront. Noncarbonated (still) water came later, but its popularity grew as people began to distrust drinking fountains (perhaps during the beginning of the AIDS crisis in the early 1980s, when the

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method of contagion remained unknown). As bottled water became more available for less cost and municipal utilities added more chemicals that altered tap water’s taste, consumers began to prefer bottled water and consider it to be better than tap. Today the industry offers hundreds of water products that, collectively, compete effectively with sweetened soft drinks.

THE CONTROVERSY “No one should assume that just because he or she purchases water in a bottle that it is necessarily any better regulated, purer, or safer than most tap water,” the Natural Resources Defense Council (NRDC) said in its report to the U.S. FDA in February 1999. The NRDC took on the issue of bottled water purity as the market for these supposedly pristine products began to ramp up, moving from barely $1 billion in sales in 1988 to more than $4 billion just ten years later. The report cited dozens of ads in magazines, in newspapers, and on television with footage of “towering mountains, pristine glaciers, and crystal-clear springs nestled in untouched forests yielding absolutely pure water.” Only a fraction of the water sold in bottles, however, actually came from these unspoiled sources—in fact, much of it came out of the tap at a bottling facility. (Tap water is regulated by the Environmental Protection Agency, not the FDA, an arrangement that widens the gap between safety standards for each.) Some bottled water even came from sources less pure than the drinking water consumers had in their own homes. “People spend from 240 to over 10,000 times more per gallon for bottled water than they typically do for tap water,” the report continued, but the bottling companies deliberately misled consumers. One brand, the NRDC discovered, took its bottled water from a well in the factory’s parking lot, which stood near a “hazardous waste dump, and periodically was contaminated with industrial chemicals at levels above FDA standards.” The NRDC estimated that as much as 40 percent of bottled water came right out of the tap, and most of this received no additional treatment before it landed on store shelves. How could this be? At the time, the FDA did not apply its rules for bottled water purity to water packaged and sold within the same state. Most states had their own regulations that covered these water products, but some did not. In addition, the FDA exempted carbonated water from its standards, setting “no specific contamination limits” on seltzers. The NRDC’s revealing and detailed report led to much more stringent FDA standards for bottled water, which in turn led to labeling that defined exactly where the water in the bottle had originated and what had been done to it before bottling. This is the origin of the many different classifications for bottled water we now see on store shelves. Forty states continue to regulate bottled water that is acquired and packaged within the state (and as of this writing, ten states don’t bother). The new standards also strengthened the perception that bottled water in just about any form must be purer than tap water, a point of view that sent

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sales skyrocketing and opened the market to all kinds of new ways to purify and fortify water. So some baselines are in place to keep bottled water relatively pure, but consumers are still left with nearly a dozen different classifications for water, some of which make startling claims about their healthfulness. This creates a difficult field to navigate, whether consumers want some kind of vitamin or mineral boost for their body’s benefit or simply seek to stay hydrated. Water labeled artesian, demineralized, purified, sparkling (plain), spring, or well water is simply water, some of which has been filtered to remove things that may affect its taste or purity. Each of these is labeled to explain its ultimate origin, while some labels provide additional information about the purification process the water has undergone since it was acquired. This still can be confusing, however, because each state regulates its own water within the state, resulting in different terminology in one state versus another. The savvy water consumer (i.e., one who has not simply installed a water filter at home, which will remove the same impurities and chemicals that water bottlers do) will read the label carefully to be sure he or she is not spending several dollars per bottle to purchase water no purer than what they already have in their home’s pipes. Water bottlers are quick to embrace ways to position their products as carriers of special health benefits. Alkaline water, for example, has attempted to play a role in bringing the benefits of antioxidants to people with high blood pressure, diabetes, high cholesterol, and acid reflux, providing an aid to cleanse the colon and achieve overall detoxification. It has been touted as a way to make the entire human body less acidic, something that sounds desirable but is actually unnecessary—the healthy human body takes care of this process itself. The body will react to too much alkalinity, though, with a condition called metabolic alkalosis, which causes nausea, vomiting, tremors, muscle twitches, confusion, and other unpleasantness. For those who suffer from acid reflux disease, however, reduction in acidity seems like an important goal. Indeed, alkaline water may help with this condition: A laboratory study conducted in 2012 found that alkaline water with a pH of 8.8 permanently inactivated pepsin in a test tube, the substance in the body that causes acid reflux. This may be a useful discovery, said Jamie Koufman, MD, the physician who conducted this research, but she later told Microsoft News that “no science backs the claim that drinking alkaline water changes the entire pH balance of the body.” This is because hydrochloric acid, one of the natural digestive chemicals in the stomach, neutralizes the pH in the water before the body can absorb it. It then disposes of any extra pH in urine, bypassing the bloodstream altogether. “You’re probably better off just drinking lemon water,” she concluded. The Mayo Clinic concurs, noting that more research will be required to verify any other claims made by alkaline water bottlers that their product may have a beneficial effect on cancer, heart disease, or bone loss (Zeratsky, 2019). Many consumers have turned to sparkling waters, particularly the unsweetened but slightly flavored ones, as an alternative to sweetened soft drinks. While

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these seltzers offer a noncaloric option with the pleasant fizz of sodas, they do have at least one drawback: The carbonation can damage tooth enamel. A study published in 2018 in the Korean Journal of Orthodontics tested the effects of carbonated water on premolar teeth and found significant changes in microhardness of the teeth submerged for fifteen minutes three times a day for a week. The study concluded that carbonated water has a negative effect on etched or sealed tooth enamel. Finally, no discussion of bottled water can be complete without addressing the effects of the bottles themselves. Plastic bottles can contain bisphenol A (BPA), a structural component in plastic, which has been in use since the 1960s. BPA has the ability to bind with estrogen in the human body, so a number of studies have explored how much BPA actually migrates from the water bottle into the consumer’s body and its potential for harmful effects. Some of these studies have found trace amounts of BPA in subjects’ biology, but they have not drawn conclusions about what effect this component may have on people’s health. A longitudinal study currently in progress at ten universities under the auspices of the National Toxicology Program and the FDA’s National Center for Toxicological Research is attempting to understand how these small amounts of BPA may affect a wide range of organs in rats. In the interim, the FDA’s current advisory is that “BPA is safe at the current levels occurring in foods. Based on FDA’s ongoing safety review of scientific evidence, the available information continues to support the safety of BPA for the currently approved uses in food containers and packaging.” That being said, FDA did amend its food additive regulations to eliminate the use of BPA in infant formula bottles, baby bottles, and sippy cups, because manufacturers took the step of abandoning the use of the component in their products.

FURTHER READINGS “2019 State of the Beverage Industry: Bottled Water Remains #1.” Beverage Industry, July 15, 2019. Accessed Aug. 23, 2019. https://www.bevindustry.com/articles/92234 -2019-state-of-the-beverage-industry-bottled-water-remains-no-1 “A Brief History of Bottled Water in America.” Great Lakes Law, Mar. 2009. Accessed Aug. 25, 2019. https://www.greatlakeslaw.org/blog/2009/03/a-brief-history-of-bottled -water-in-america.html “Bisphenol A (BPA): Use in Food Contact Application.” U.S. Food & Drug Administration. Accessed Jan. 28, 2020. https://www.fda.gov/food/food-additives-petitions /bisphenol-bpa-use-food-contact-application DiNuzzo, Emily. “This Is What Alkaline Water Really Does to Your Body.” MSN Lifestyle, Microsoft News, Mar. 15, 2019. Accessed Aug. 23, 2019. https://www.msn .com/en-us/health/health-news/this-is-what-alkaline-water-really-does-to-your-body /ar-BBUMWQL Eske, Jamie. “What Are the Health Benefits of Mineral Water?” Medical News Today, Apr. 9, 2019. Accessed Aug. 23, 2019. https://www.medicalnewstoday.com/articles /324910.php

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Goldman, Rena; and Nagelberg, Rachel. “Alkaline Water: Benefits and Risks.” Healthline, May 30, 2019. Accessed Aug. 23, 2019. https://www.healthline.com/health/food -nutrition/alkaline-water-benefits-risks#benefits Koufman, J.A.; and Johnston, N. “Potential Benefits of pH 8.8 Alkaline Drinking Water as an Adjunct in the Treatment of Reflux Disease.” Annals of Otology, Rhinology & Laryngology, July 2012, 121(7), 431–434. Accessed Aug. 23, 2019. https://www.ncbi .nlm.nih.gov/pubmed/22844861 Olson, Erik D., with Poling, Diane; and Solomon, Gina. “Bottled Water: Pure Drink or Pure Hype?” Natural Resources Defense Council, Feb. 1999. Accessed Aug. 23, 2019. https://www.nrdc.org/sites/default/files/bottled-water-pure-drink-or-pure-hype-report .pdf Postman, Andrew. “The Truth About Tap.” Natural Resource Defense Council, Jan. 5, 2016. Accessed Aug. 23, 2019. https://www.nrdc.org/stories/truth-about-tap?gclid=C jwKCAjwnf7qBRAtEiwAseBO_DS7a3j3cnqeI-uepd8VloMC96E5n4-mV17Pw7G W9IU9b-ORzviNohoCPfsQAvD_BwE Ryu, Hyo-kyung; Kim, Yong-do; Heo, Sung-su; and Kim, Sang-cheol. “Effect of Carbonated Water Manufactured by a Soda Carbonator on Etched or Sealed Enamel.” Korean Journal of Orthodontics, Jan. 2018, 48(1), 48–56. Accessed Aug. 23, 2019. https://www .ncbi.nlm.nih.gov/pmc/articles/PMC5702778/ Zeratsky, Katherine. “Is Alkaline Water Better for You That Plain Water?” Mayo Clinic. Accessed Aug. 23, 2019. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and -healthy-eating/expert-answers/alkaline-water/faq-20058029

Caffeine WHAT IS IT? Caffeine is an alkaloid compound in the class of methylxanthines, which occurs naturally in coffee, tea, cacao, and cola plants, as well as in guarana and yerba mate plants. This bitter-tasting crystal stimulates the central nervous system, increasing brain activity and making people feel more awake, energetic, and alert and even increasing their sociability and their overall sense of well-being. It also serves as a natural diuretic, increasing urination. Pharmaceutical companies synthesize caffeine in a laboratory and add it to over-the-counter medications that would otherwise make people drowsy, including allergy medications like antihistamines. Analgesics used for migraines often contain caffeine, as its ability to constrict blood vessels in the brain can provide quick relief for these debilitating headaches. Consumers can buy concentrated caffeine tablets or capsules with brand names like No Doz® and Vivarin® to combat fatigue. Most recently, lab-synthesized caffeine has become a central ingredient in a wide range of energy drinks, from tiny bottles of 5-Hour Energy® to cans of soft drinks like Red Bull®.

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In addition to its positive effects, caffeine can produce negative symptoms in people who overuse it or who have a greater sensitivity to its effects. Anxiety and “jitters” are often side effects of caffeine use. In people who have heart conditions, caffeine use can trigger palpitations, a rise in blood pressure, and other symptoms, though it has not been found to actually damage the heart. Too much caffeine—more than 400 mg a day in a healthy person, according to the FDA—can raise blood pressure, increase heart rate, and cause sleeplessness. Frequent users can build up a tolerance to caffeine, making it necessary to take in larger amounts to achieve the desired effect. This is a sign of addiction, which can lead to significant withdrawal symptoms if caffeine use stops abruptly: severe, throbbing headaches; sleepiness, mood changes, irritability, and even vomiting.

CURRENT CONSUMPTION STATISTICS AND TRENDS Actual usage statistics are hard to come by, but a look at sales of caffeinated beverages provides a solid picture of their use around the world. • The Journal of the American Dietetic Association published a 2005 paper that stated that 90 percent of the world’s population uses caffeine regularly. Most of these people take in about 200 mg per day—the approximate equivalent of two cups of coffee. • The International Coffee Organization reports that from July 1, 2018, to June 30, 2019, worldwide coffee bean exports totaled 168.77 million bags, with a bag weighing 132.276 pounds (60 kg). That’s a total of 22.3 billion pounds of coffee beans. This represents an 8 percent increase over the previous year, indicating that coffee consumption is rising. • The market for tea in the United States continues to expand by 6.9 percent annually, with a predicted $214.7 million in 2019. These figures are limited to black and green tea, both of which are usually caffeinated; they do not include herbal, instant, iced, or ready-to-drink teas. • Coca-Cola reports that worldwide consumers drink more than 1.9 billion cans and bottles of their products every day. While not all of these products are caffeinated—Coke owns a number of caffeine-free beverages and bottled water brands—Coca-Cola’s original cola brand continues to be the number one selling soft drink in the United States. • The popularity of energy drinks continues to rise, with 6.8 billion cans of Red Bull sold worldwide in 2018. The National Center for Complementary and Integrative Health reports that energy drinks are “the most popular dietary supplement consumed by American teens and young adults,” second only to multivitamins. Men between the ages of eighteen and thirty-four are the largest audience for these drinks, with adolescents between twelve and seventeen years the next biggest group of consumers.

NUTRITIONAL INFORMATION Generally, an 8-ounce cup of coffee contains somewhere between 80 and 100 mg of caffeine. A cup of black or green tea may contain 30–50 mg, while a 12-ounce can of a caffeinated soft drink usually provides 30–40 mg.

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Energy drinks contain a great deal more caffeine than a typical cup of coffee. A 16-ounce can of Monster Energy or Rockstar energy drink, for example, contains 160 mg of caffeine, while a 24-ounce can of Rockstar Punched provides 360 mg of caffeine. Beyond its value as a stimulant, caffeine does not provide any nutritional content.

HISTORY The discovery of a stimulant in certain plants predates recorded history, so there’s no way to know who first determined that coffee beans, tea leaves, or cacao beans could be used as a pick-me-up. Anthropologists make an educated guess that these plants may have come to the attention of human beings as far back as 70,000 BC, with prehistoric people chewing the seeds and roots to enjoy their stimulating properties. Grinding beans may have become an easier way to access the benefits, but the process of infusing the plant material with boiling water is a far more recent phenomenon. We know that the Olmec civilization in what is now southern Mexico grew cacao and introduced the Mayan civilization to the beans somewhere around 300 BC. The Mayans, in turn, ground the beans and made them into a drink consumed only by those of the elite class. They shared it with the Aztecs, who decided it needed something more . . . so they added sugar and milk, and created the basis for what became the most popular confection in the world. (There’s much more about the evolution of chocolate later in this book.) There is no written record of the first time someone ground coffee beans and infused them with boiling water, but we do know that the use of coffee and tea plants for their ability to sharpen thinking and supply energy does seem to have increased dramatically in the fifteenth and sixteenth centuries, right about when explorers from the European nations set out to find routes to exotic locales in South America, Africa, and the Far East. By the 1600s, as ships returned to Europe fairly regularly from these regions, drinks featuring caffeine had begun to grow in popularity among the upper classes. For the most part, however, coffee and tea were seen as part of the apothecary, not a staple at breakfast or the finish of a nice meal. Robert Burton’s staggeringly extensive medical text, The Anatomy of Melancholy, first published in 1621, discusses coffee as a medicine. He notes its usefulness in producing an antidote to melancholy, its worth as a stimulant, and its positive effect on digestion. This usage persisted throughout the fifteenth century, with physicians of the time crediting coffee as a cure for everything from coughs and colds to the bubonic plague. Tea, meanwhile, may have originated in China around 3000 BC. The legend goes that when Shennong, the emperor at the time, accidentally dropped some leaves into boiling water, he noted that they produced a pleasing aroma. He sampled the resulting beverage and not only enjoyed the flavor, but he recognized the burst of energy he felt shortly thereafter as coming from the tea. Civilizations

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in other parts of the world discovered tea in their own time: archaeologists have found it in the relics of Native American tribes dating back thousands of years, so it’s conceivable that tea emerged in the western hemisphere concurrently with its use in Asia. Tea also served as a medicinal drink—in fact, the only way it was permitted into England during the Cromwell Protectorate in the mid-1600s was as a curative for various ailments. By this time, Chinese physicians had used tea leaves sanitized in boiling water as a tonic since AD 350, further confirming its usefulness. Once the protectorate dissolved and imports from China became more regular, tea grew to become the drink of choice in the United Kingdom, putting it on a parallel path with coffee for the most desired caffeinated drink. One testament to coffee’s quickly growing popularity in Europe is the “Coffee Cantata,” a composition by Johann Sebastian Bach, written in 1734 to lyrics supplied by poet Picander. The song celebrates Zimmerman’s Coffee House in Germany, where Bach and his students often performed: Ah! How sweet the coffee’s taste is, Sweeter than a thousand kisses, Milder than sweet muscatel. Coffee, coffee, I must have it, And if someone wants to treat me, Ah, my cup with coffee fill! Something so beneficial to concentration and productivity could only gain momentum, so by the nineteenth century, coffee and tea held places in every corner of society. Still, the specific element that gave these drinks their energyboosting ability had not yet been discovered. In 1819, a German chemist named Friedlieb Ferdinand Runge isolated the compound in coffee that provided the energy and medicinal value and named it kaffebase—translating to “coffee base.” Word did not travel around the world the way it does today, of course, so when three scientists in France isolated the chemical independently in 1821, they felt they could lay claim to the discovery. Pierre Jean Robiquet, Pierre-Joseph Pelletier, and Joseph Bienaimé Caventou did receive their places in history, as they apparently arrived at their conclusions without any knowledge of Runge’s work. Robiquet managed to make the first presentation of the discovery at the Pharmacy Society meeting later that year, so he received the accolades; meanwhile, Pelletier published an article in which he named the compound caffeine, sealing his own spot in the annals of history. Germany claimed one more scientific victory in the development of caffeine as a marketable commodity: Chemist Hermann Emil Fischer became the first to synthesize the compound in a laboratory, making it possible to create caffeine without the costly process of harvesting plants that only grow in exotic locations. He received the Nobel Prize in 1902 for his work in chemical reactions and

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processes for synthesizing chemicals. (In a remarkable feat of symmetry, he is also the discoverer of barbiturates—sedatives used to combat insomnia.) With a process for synthesizing caffeine at the ready, mass production and marketing of all manner of caffeinated beverages could begin. By the twentieth century, “the cultural life of caffeine, as transmitted through the consumption of coffee and tea, had become so interwoven with the social habits and artistic pursuits of the Western world that the coffee berry had become the biggest cash crop on earth, and tea had become the world’s most popular drink,” wrote Bennett A. Weinberg and Bonnie K. Bealer in their book The World of Caffeine: The Science and Culture of the World’s Most Popular Drug.

THE CONTROVERSY People use caffeine because of its pleasant effects, so it may come as no surprise that the drug has been credited with all kinds of benefits to body and mind. In recent years, scientists have begun to test claims about caffeine’s potential medicinal uses. An article on the caffeine-centered website CaffeineInformer.com touts the “Top 25+ Caffeine Health Benefits,” with links to studies—some credible, some less so—that suggest that caffeine helps grow hair on men’s heads, relieves pain, prevents skin cancer, protects against cataracts, and reverses Alzheimer’s disease. Many of these studies look at data rather than performing research on actual patients. While examining lifestyle and habits of patients can be a perfectly valid way to determine a correlation between variables, more research would be required to make the leap from correlation to causation. An examination of caffeine consumption in patients who have a specific genetic marker for Parkinson’s disease, for example, appears to show that patients who consume caffeine had a significantly lower risk of actually developing the disease than people who do not use caffeine. “Whether there is an actual biological interaction between caffeine mediated downstream pathways needs to be further investigated in both in vitro studies and in animal models,” the study’s authors noted (Prakash, 2015). The claim that caffeine will grow hair comes from a study involving scalp biopsies from fourteen men who were experiencing male pattern baldness. The biopsies were tested in a laboratory, first with testosterone, resulting in “significant growth suppression,” and then with tiny amounts of caffeine. “Caffeine alone led to a significant stimulation of hair follicle growth,” the report noted (Fischer, 2007). Since then, hair products containing caffeine have come to market, and a 2017 study conducted in India and Germany followed 210 men for six months to see if caffeine could be as effective as minoxidil, the approved treatment for hair loss. Caffeine applied topically to the hair follicles did indeed seem nearly as effective. Just drinking beverages with caffeine does not deliver enough of the drug to grow hair, however; scientists note that about 6,000 mg of caffeine would have to be ingested daily, which is far more than anyone can take in safely.

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Stories have circulated over the last several years about caffeine’s role in preventing liver cancer. The most recent credible studies (i.e., with no apparent involvement of the coffee industry) suggest that coffee—not caffeine—may reduce the risk of liver cancer and other liver diseases by as much as 40 percent (Tamura, 2018). In addition, a 2010 study at the University of Maryland determined that caffeine eye drops given to rats with cataracts prevented progression of their cataracts, while rats that received a placebo eye drop had more severe cataracts (Shambhu, 2010). These results have been replicated in further studies involving humans, including one in 2019. Drinking beverages with caffeine appears to help as well, as a 2016 study noted. Caffeine may have many pharmaceutical uses, but its psychoactive effect on the body classifies it as a drug, and drug abuse leads to negative effects. Unregulated and legal in every country, caffeine has taken a place as the most widely used drug in the world, even more so than alcohol or nicotine. Addiction is a distinct possibility, as is building up a tolerance to caffeine’s stimulating effect, requiring more and more intake to achieve the desired “high.” The FDA recommends that caffeine users limit their consumption to 400 mg a day (or less). This amounts to four or five cups of coffee or up to ten 12-ounce cans of a caffeinated soft drink or as many as thirteen cups of tea. Energy drinks meet the 400-mg limit with less than three 16-ounce cans per day or with just one 24-ounce can of an “amped” energy drink. A standard bottle of an energy shot drink (such as 5-Hour Energy) delivers about 215 mg or just over half the RDA of caffeine. Users who stay under the FDA’s recommended intake may see more benefits than drawbacks to caffeine use. Caffeine used responsibly can help with weight loss, sharpen thinking, increase alertness, and improve mood. Most users have nothing to fear from a couple of cups of coffee a day unless they are particularly sensitive to caffeine’s effect. People who experience tremors in their hands, increased anxiety, or palpitations from caffeine consumption may be more comfortable without the additional stimulation. None of these symptoms are permanent, so they will subside once the caffeine has run its course. As with all drugs, however, caffeine can become destructive when abused. Teens and young adults who drink highly caffeinated energy drinks on a habitual basis are likely to take more risks, experience more depression, and see increases in blood pressure. (Many of these drinks are also high in sugar, which increases the risk of heart disease and type 2 diabetes.) The Center for Behavioral Health Statistics and Quality released a report in 2013 on the increase in the number of emergency room visits that resulted from overuse of energy drinks: Emergency visits doubled from 2007 to 2011, to more than 20,000 visits, with symptoms including insomnia, nervousness and anxiety, headache, seizures, and pounding heartbeat. “This report validates claims that energy drinks can be dangerous when used alone or in combination with other drugs or alcohol,” author Margaret E. Mattson, PhD, concluded.

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The Journal of Caffeine Research published an extensive literature review in 2013 on caffeine use disorder (also known as caffeine dependence syndrome), a clinical condition recognized by the World Health Organization. The paper describes the disorder as a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and which typically include a strong desire to take the drug, difficulties in controlling use, persisting in use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. (Meredith et al., 2013)

People with this disorder have become physically dependent on the drug and cannot reduce their usage, even when they know their caffeine consumption causes health issues. Moderate caffeine use can produce withdrawal symptoms including headache, fatigue, lowered mood, and trouble focusing on a task, and these send users running back to the coffeemaker for another cup. When a heavy caffeine user experiences withdrawal, it can come with throbbing migraine headaches, nausea and vomiting, depression, and more— and the desire to return to the elevated mood and functionality that caffeine brings may become permanent, even after the physical dependence has been overcome. How big a problem is caffeine dependence? Studies have not produced a clear response to this question to date, with some suggesting that only about 6 percent of all caffeine users may have this disorder and another noting that it may be as high as 30 percent. There are enough cases to fill meetings of the 12-step Caffeine Addicts Anonymous program across the country, although the participants in these meetings self-select to attend, so their definitions of caffeine dependence may vary widely.

FURTHER READINGS “Caffeine: Facts, Usage, and Side Effects.” Caffeine Informer. Accessed Aug. 26, 2019. https://www.caffeineinformer.com/caffeine-trimethylxanthine “The Company Behind the Can.” Red Bull. Accessed Aug. 26, 2019. https://energydrink -us.redbull.com/en/company “Consumption of Caffeinated Energy Drinks Rises in the United States.” Science Daily, Apr. 29, 2019. Accessed Aug. 27, 2019. https://www.sciencedaily.com/releases/2019 /04/190429125416.htm “Energy Drinks.” National Center for Complementary and Integrative Health. Accessed Aug. 26, 2019. https://nccih.nih.gov/health/energy-drinks Fray, C.D.; Johnson, R.K.; and Wang, M.Q. “Food Sources and Intakes of Caffeine in the Diets of Persons in the United States.” Journal of the American Dietetic Association, Jan. 2005, 105(1), 110–113. Accessed Aug. 27, 2019. https://www.ncbi.nlm.nih.gov /pubmed/15635355/

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International Coffee Organization. Accessed Aug. 26, 2019. http://www.ico.org Kumar, Prakash M., et al. “Differential Effect of Caffeine Intake in Subjects with Genetic Susceptibility to Parkinson’s Disease.” Scientific Reports, Nov. 2, 2015, 5. Accessed Aug. 27, 2019. https://www.nature.com/articles/srep15492 Mattson, Margaret E. “Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern.” The CBHSQ Report, Substance Abuse and Mental Health Services Administration, Jan. 10, 2013. Accessed Aug. 27, 2019. https://www.ncbi.nlm.nih.gov/books/NBK384664/ Meredith, Steven E., et al. “Caffeine Use Disorder: A Comprehensive Review and Research Agenda.” Journal of Caffeine Research, Sept. 2013, 3(3), 114–130. Accessed Aug. 27, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777290/ “Spilling the Beans: How Much Caffeine Is Too Much?” U.S. Food & Drug Administration, Dec. 12, 2018. Accessed Aug. 26, 2019. https://www.fda.gov/consumers /consumer-updates/spilling-beans-how-much-caffeine-too-much Tamura, T., et al. “Coffee, Green Tea, and Caffeine Intake and Liver Cancer Risk: A Prospective Cohort Study.” Nutrition and Cancer, 2018 Nov-Dec: 70(8), 1210–1216. Accessed 27 Aug 2019. https://www.ncbi.nlm.nih.gov/pubmed/30457014 Varma, Shambhu D., et al. “Effectiveness of Topical Caffeine in Cataract Prevention: Studies with Galactose Cataract.” Molecular Vision, Dec. 2, 2010, 16, 2626–2633. Accessed Aug. 27, 2019. http://www.molvis.org/molvis/v16/a281/ Weinberg, Bennett Alan; and Bealer, Bonnie K. The World of Caffeine: The Science and Culture of the World’s Most Popular Drug. New York: Routledge, 2001.

Carbonated Beverages WHAT ARE THEY? Carbonated beverages contain dissolved carbon dioxide added to liquid under high pressure. When the pressure is released, the carbon dioxide produces bubbles (effervescence). Fizzy soft drinks (soda pop), sparkling water, some mineral waters, sparkling wine, and others are all carbonated beverages. Some of these (mineral water in particular) come by their bubbles naturally in underground springs, but most obtain their carbon dioxide through an industrial process.

CURRENT CONSUMPTION STATISTICS AND TRENDS Many carbonated beverages contain sugar in some form, whether it is highfructose corn syrup, cane sugar, fructose, sucrose, or one of many other kinds of highly caloric sweetener. With the availability of information about the link between sugary drinks and obesity, diabetes, and heart disease, consumption of these beverages has declined steadily since 2003, according to the ongoing

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National Health and Nutrition Examination Survey. That being said, a survey published in 2017 determined that 50 percent of adults and 60.7 percent of children in the United States drank a sugary beverage daily. While these figures were down from previous years (79.7 percent of children and 61.5 percent of adults in 2003), they still represent a multibillion-dollar industry. Instead, many consumers have chosen sparkling water as their go-to beverage, a carbonated product that contains nothing but water and carbon dioxide. Some sparkling water products also contain noncaloric flavors, which manifest mostly as scents to provide a mild sense of flavor without adding sugar. Nielsen Retail Measurement Services, the tracker of barcode scans at the register for many industries, notes that from 2014 to 2018, the sparkling water category grew 54 percent. According to Nielsen, from August 1, 2017, through July 28, 2018, sales of sparkling water hit $2.2 billion, and canned carbonated water—including the many flavored varieties—grew 43 percent over the previous year. In one week alone in the summer of 2018, Nielsen clocked sales of more than $21 million for canned sparkling water.

NUTRITIONAL INFORMATION Carbonated water is just water, so it has no nutritional content in and of itself. As a key to hydration, it provides all of the hydration value of plain (still) water, with the added refreshment of fizz. Carbonated soft drinks may contain high levels of sugar and sodium, both of which can have a detrimental impact on health. Drinks that are high in sugar and salt contribute to heart disease, type 2 diabetes, stroke, and other illnesses brought on by obesity.

HISTORY Joseph Priestly, an English philosopher and chemist, earned his place in history with his discovery of oxygen and carbon monoxide, but his exploration of the “airs” we breathe eventually led him to infuse water with carbon dioxide in 1767. The resulting bubbly water did not become the focus of his work, but it held more interest for Torbern Bergman, a Swedish chemist who discovered carbonation independently in 1771 and apparently without knowledge of Priestly’s discovery. He used sulfuric acid in chalk to create a process for carbonation, but he also did not see a lot of practical application for this technique and soon moved on to other experiments. In 1783, J.J. Schweppe invented a way to produce carbonated water on a large scale. His method quickly drew the attention of other entrepreneurs, including Augustine Thwaites, an Irishman who was the first to call the beverage “soda water.” The novel beverage’s popularity grew as various businesses sprang up to offer it, each adding a wide range of flavors to attract customers away from competitors and into their own establishments.

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It took American inventor John Matthews to build a machine in 1832 that could infuse plain water with carbon dioxide and then sell that machine to businesses, to turn carbonated beverages into a mass-market enterprise. By this time, flavored fizzy drinks had come to America with fruit flavors as well as sarsaparilla, birch bark, and dandelion, but the availability of Matthews’ machine turned every pharmacy store into a soda fountain. Soon consumers wanted to be able to enjoy their soda pop at home, so inventors began working to find a way to keep the pressurized drinks in bottles without their going flat. This feat required many incremental patents until 1892, when William Painter of Baltimore created what he named the Crown Cork Bottle Seal, the first bottle top that preserved the fizz. Seven years later, Libby Glass Company patented a bottle that could be mass produced, the brainchild of staff inventor Michael Owens. Carbonated beverages soon arrived on store shelves, and in the 1920s, six-pack design and vending machines became the breakthrough inventions that brought soft drinks into every household, automobile, and workplace in the country.

THE CONTROVERSY Carbonation has been blamed for a wide range of health issues in the popular press, from acid reflux to bone density loss and tooth enamel decay. Some of these claims result from a misreading of clinical studies in which reporters generalized the results of tests to include all carbonated beverages, instead of the soft drinks that actually contribute to the health issue. For example, a 2006 study published in the American Journal of Clinical Nutrition did its best to clarify its own results with the title, “Colas, but Not Other Carbonated Beverages, Are Associated with Low Bone Mineral Density in Older Women.” This study, conducted as part of the Framingham Osteoporosis Study at Tufts University, discovered that cola drinks actively reduced bone density in the hips of postmenopausal women, while other carbonated beverages did not. (See Phosphorus-Containing Food Additives for more on this.) The claim that carbonated beverages may contribute to gastroesophageal reflux disease (GERD, also known as acid reflux) has also been proved false. Carbonation may create pressure in the stomach that relaxes the lower sphincter of the esophagus, which may temporarily irritate the esophagus if acid reflux is already present. A study conducted at the University of Arizona in 2010 and published in the peer-reviewed Alimentary Pharmacology and Therapeutics, however, tested and discredited the rumor that carbonation actively causes GERD. The researchers discovered that carbonation creates “a very short decline in intraoesophageal pH,” but “there is no evidence that carbonated beverages directly cause oesophageal damage. . . . Furthermore, there is no evidence that these popular drinks lead to GERD complications or oesophageal cancer.” News that carbonated beverages cause kidney stones received the same kind of media distortion, even though the study that determined this actually focused on cola. The phosphoric acid in cola beverages increases the risk of chronic kidney

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disease, a study of data from 465 patients in North Carolina determined. The study, published in the journal Epidemiology, concluded that people who drank two or more colas per day (we can assume that this refers to the standard 12-ounce cans) had an increased risk of chronic kidney disease, whether they drank fullstrength sugared cola or artificially sweetened varieties. The presence of carbonation was not a factor in the higher risk. “Noncola carbonated beverages were not associated with chronic kidney disease,” the study concluded. The one area in which carbonation has a mildly damaging effect is in tooth enamel. Carbonation produces carbonic acid, which lowers a beverage’s pH. This can contribute to the erosion of the coating on the outside of teeth. Beverages with a pH below 4.0—more than 93 percent of carbonated beverages, according to a study published in the Journal of the American Dental Association in 2016—are more corrosive than those with a pH above 4. For the most part, sparkling waters—the ones without sugar or other additives—had a pH of above 4.0, earning them a ranking of “minimally corrosive.” The American Dental Association concurs with this, sharing the results of a study on teeth that were donated for research, in which they were tested to see if sparkling water was more corrosive than regular still water. “The two forms of water were about the same in their effects on tooth enamel,” the ADA summarized. “This finding suggests that even though sparkling water is slightly more acidic than ordinary water, it’s all just water to your teeth.” The ADA still recommends plenty of regular, fluoridated water for tooth health, but sparkling water is a good alternative to sugary drinks. In summary, the bubbles are not the problem; it’s the sugar and sodium in most carbonated drinks and the acidic nature of cola that have the most destructive effects on the human body.

FURTHER READINGS Bellis, Mary. “Introduction to Pop: The History of Soft Drinks.” ThoughtCo., June 26, 2019. Accessed Aug. 28, 2019. https://www.thoughtco.com/introduction-to-pop-the -history-of-soft-drinks-1991778 “Get the Facts: Sugar-Sweetened Beverages and Consumption.” Centers for Disease Control and Prevention. Accessed Aug. 28, 2019. https://www.cdc.gov/nutrition/datastatistics/sugar-sweetened-beverages-intake.html “Invention of Carbonation and History of Carbonated Water.” History of Soft Drinks. Accessed Aug. 28, 2019. http://www.historyofsoftdrinks.com/soft-drink-history/history -of-carbonated-water/ “Is Sparkling Water Bad for My Teeth?” Mouth Healthy, American Dental Association. Accessed Aug. 28, 2019. https://www.mouthhealthy.org/en/nutrition/food-tips/the -truth-about-sparkling-water-and-your-teeth?_ga=2.209146898.1056501.1567015881 -730615661.1567015881 Johnson, T., et al. “Systematic Review: The Effects of Carbonated Beverages of Gastrooesophageal Reflux Disease.” Alimentary Pharmacology and Therapeutics, Feb. 9, 2010.

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Accessed Aug. 28, 2019. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036 .2010.04232.x Lambert, C.P., et al. “Fluid Replacement After Dehydration: Influence of Beverage Carbonation and Carbohydrate Content.” International Journal of Sports Medicine, 1992, 13(4), 285–292. Accessed Aug. 28, 2019. https://www.thieme-connect.com/products /ejournals/abstract/10.1055/s-2007-1021268 “No Signs of Fizzing Out: America’s Love of Sparkling Water Remains Strong Through August.” Nielsen, Aug. 24, 2018. Accessed Aug. 28, 2019. https://www.nielsen.com/us/en/insights /article/2018/no-signs-of-fizzing-out-americas-love-of-sparkling-water-remains-strong/ Reddy, Avanija, et al. “The pH of Beverages in the United States.” Journal of the American Dental Association, Apr. 2016, 147(4), 255–263. Accessed Aug. 28, 2019. https://jada.ada.org/article/S0002-8177%2815%2901050-8/abstract?_ga=2.77880468 .1056501.1567015881-730615661.1567015881 Saldana, Tina M., et al. “Carbonated Beverages and Chronic Kidney Disease.” Epidemiology, July 2007, 18(4), 501–506. Accessed Aug. 28, 2019. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC3433753/ Specktor, Brandon. “Is Sparkling Water as Healthy as Regular Water?” LiveScience, Apr. 19, 2018. Accessed Aug. 28, 2019. https://www.livescience.com/62351-does-sparkling -water-hydrate-you.html Tucker, Katherine, et al. “Colas, But Not Other Carbonated Beverages, Are Associated with Low Bone Density in Older Women: The Framingham Osteoporosis Study.” The American Journal of Clinical Nutrition, Oct. 2006, 84(4), 936–942. Accessed Aug. 28, 2019. https://academic.oup.com/ajcn/article/84/4/936/4632980

Carrageenan WHAT IS IT? Carrageenan is a substance derived from red seaweed—also known as Irish moss—that is used to thicken and preserve a number of foods. You may see it listed in the ingredients of yogurt products, processed meats, milk made from nuts or soy, ice cream, whipped toppings, baby formula, chocolate milk, fancy coffee beverages, coffee creamer, and dairy products like cottage cheese and sour cream. The market for carrageenan extends to the cosmetics and pharmaceutical industry, but dairy products and meats tend to see the largest share of usage. In particular, carrageenan keeps whey from separating out of cottage cheese and ice cream, a problem that comes from additives used in these products for other purposes. In the delicatessen (and also in pet foods), carrageenan helps retain soluble protein in hams and processed meats, binding the proteins and keeping these products intact.

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CURRENT CONSUMPTION STATISTICS AND TRENDS The entire world uses carrageenan as a product in food production, to the tune of U.S. $864.3 million in 2019. This momentum drove Mordor Intelligence to forecast that the global market will reach U.S. $1.45 billion by 2024. The world’s demand for processed foods with organic ingredients drives the upward thrust of this market, with carrageenan’s overall versatility and effectiveness making it the most popular thickener, gelling agent, and stabilizer for dairy products and meats, as well as a wide range of other foods. As countries in the Asia Pacific region ratchet up their own demand for prepackaged foods in recent years, the carrageenan market can expect to continue to expand.

NUTRITIONAL INFORMATION Carrageenan does not add calories to food; nor does it add fat, sodium, cholesterol, or any other nutrient. Its contribution comes in supporting thick, creamy texture, stabilizing dairy products, and making low-fat and low-sugar foods feel as good in our mouths as their full-fat analogs. It also adds fiber, allowing foods that would otherwise have no fiber content to gain this healthful benefit.

HISTORY To obtain carrageenan, food scientists follow a simple process that has been in use since the fifteenth century: They boil the seaweed, filter the carrageenan out of the broth, dry it, and mill it until they have a powder that can be mixed into many different foods. This is the process used by Irish cooks as far back as the 1400s, when they employed it to thicken soups and puddings, according to FoodScienceMatters.com. Carrageenan’s use dates back even farther than that, however. Archaeologists have discovered evidence among ancient relics in Chile that preserving seaweed and its by-products took place thousands of years before the modern era. The Chinese farmed seaweed in 2700 BC, and they began using red algae as a medicine around 600 BC. Antiquated Irish records note the use of the seaweed byproduct as a thickener by 400 BC, and in the 1400s, seaweed became a staple in Korean cooking. Its use as a commercial thickener began in the mid-1800s in the United States, when an Irishman named Daniel Ward recognized the red seaweed in the waters off the coast of Massachusetts. He established his family’s home in Scituate, Massachusetts, and began harvesting the plant using the old family method. Soon his enterprise grew to include many other Irish immigrants, who worked together to harvest the steady supply of “Irish moss” and boil it down for the valued powder. Nearly 100 years passed before carrageenan became the dominant thickener in food processing—and like many other products, it came to the fore during a world war. With the United States at war with Japan, the supply of agar, a thickener

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derived from a red algae that grows in the waters off Japan’s shores, became limited enough to curtail production of a number of foods. The Scituate enterprise stood ready, however, to do its patriotic duty and replace the need for agar with the more versatile carrageenan. By the time the war ended, the food industry had embraced carrageenan as its primary thickener, and U.S. suppliers met the demand by reaching out to the warm waters of the South Pacific Ocean for mass cultivation of the appropriate seaweed. This brought new industry to countries in the Indian Ocean and around the Pacific Rim, creating jobs for many people who were struggling to survive after the war. Today carrageenan production is a major industry in a number of developing countries, involving up to 100,000 families on five continents in the global enterprise.

THE CONTROVERSY Despite carrageenan’s benefits to food appearance and texture, its natural origins, and the gentle process with which its harvesters extract it from seaweed, carrageenan has become the subject of considerable controversy since 1973. The story of carrageenan’s rocky relationship with scientists, bloggers, health-food enthusiasts, and Internet rumormongers begins with that most dreaded phenomenon of modern times: questionable science. As early as 1973, the results of studies began to emerge that suggested that certain forms of carrageenan caused lesions in the colon and liver toxicity in mice and rats. In 1976, Vinegar et al. devised a process for creating inflammation in rats with carrageenan, a necessary step before using the rats to test all manner of drugs and other substances that reduce or otherwise affect swelling (edema) and inflammation. The fact that carrageenan could be used in this manner represented a warning signal for some scientists, who began studying this common food additive with more directed scrutiny. It’s important to note that the process of causing inflammation in rats calls for injection of carrageenan, not consumption, so the effect on the rat’s body is different from what happens in a human’s digestive tract. In addition, the form of carrageenan used in this manner is “degraded” carrageenan, later renamed poligeenan by the United States Adopted Names Council. Poligeenan is a polymer used in laboratories and in clinical diagnostics—for example, to suspend barium sulfate in a slurry for X-rays of the digestive tract. It is never used in food. It may be no surprise that such a substance caused internal lesions in rodents, but this has nothing at all to do with food-grade carrageenan. In fact, by 1974 scientists had begun testing the carrageenan used in food in parallel studies on mice, including one in which they fed mice skim milk that contained carrageenan for six months. The mice remained healthy and cancer-free, as did rats and hamsters that received varying dose levels of the carrageenan food additive in their daily diet throughout their lifespan. “From the results of this experiment, carrageenan demonstrated no carcinogenic effects in either species,” the latter report concluded (Rustia, p. 1).

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Studies using degraded carrageenan continued, however, and in 2001, Joanne K. Tobacman at the University of Iowa led several studies in which she concluded that carrageenan caused breast, colon, and gastrointestinal cancer. She wrote in an article in Environmental Health Perspectives in 2001: Although the International Agency for Research on Cancer in 1982 identified sufficient evidence for the carcinogenicity of degraded carrageenan in animals to regard it as posing a carcinogenic risk to humans, carrageenan is still used widely as a thickener, stabilizer, and texturizer in a variety of processed foods prevalent in the Western diet.

Degraded carrageenan had officially been renamed poligeenan in 1988 to make the distinction between it and the carrageenan used in food, but Tobacman continued to generalize the two different substances as if they were the same. The argument for this, some scientists have said, is that food-grade carrageenan degrades in the gastrointestinal system to become poligeenan. “Because of the acknowledged carcinogenic properties of degraded carrageenan in animal models and the cancer-promoting effects of undegraded carrageenan in experimental models, the widespread use of carrageenan in the Western diet should be reconsidered,” Tobacman wrote. In 2008, Tobacman petitioned the FDA to remove carrageenan from its GRAS status. The FDA reviewed the case and all of the science on both sides of the issue and finally issued a letter in 2012, reiterating the additive’s qualifications for GRAS status. Carrageenan has maintained that status since then, even though Tobacman continues to research the additive and published studies as recently as June 2019 that link the additive with cancer in rodents. One of the organizations siding with Tobacman is the Cornucopia Institute, which “provides needed information to family farmers, consumers and other stakeholders in the good food movement and to the media,” according to its website. Cornucopia published a report in 2013 titled, “Carrageenan: How a ‘Natural’ Food Additive Is Making Us Sick,” in which it summarizes the studies up to that point and expresses concern that “the acid environment of the stomach may ‘degrade’ foodgrade carrageenan once it enters the digestive system, thus exposing the intestines to this potent and widely recognized carcinogen.” It continues, “The unique chemical structure of carrageenan triggers an innate immune response in the body, which recognizes it as a dangerous invader. This immune response leads to inflammation.” Contrast this point of view with the results of a 2016 study published in Food and Toxicology and led by James M. McKim Jr., another expert in carrageenan research, who spent two years attempting to replicate Tobacman’s findings in a study sponsored by the International Food Additive Council (IFAC). The study’s conclusion: Carrageenan “has no impact on the human body when consumed in food,” said Robert Rankin, IFAC’s executive director, in a news release about the study. “Carrageenan producers have taken very seriously claims that the ingredient is unsafe, thoroughly investigated the research supporting those claims and found them to be baseless.”

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“For every seemingly irrefutable point, there seems to be an equally valid counterpoint,” wrote “Nutrition Diva” Monica Reinagel, MS, LD/N, CNS, in a column in Scientific American about the controversy. “Individuals continue to report dramatic improvement of long-standing digestive issues when they eliminate carrageenan from their diets. Activists continue to call for a ban. The food industry continues to defend its use, citing the conclusions of scientists and government agencies. What’s a consumer to do?” So the controversy continues. On one side, groups like the Cornucopia Institute brandish Tobacman’s research and insist that carrageenan is a cancer-causing agent. On the other side, IFAC and others grip McKim’s research and call Tobacman’s work “bad science.” The one thing we know for certain is that some people who have irritable bowel syndrome, ulcerative colitis, Crohn’s disease, or other gastrointestinal issues find foods that contain carrageenan to be irritating to their condition. If you have one of these illnesses, consider reducing your intake of foods that use this additive. You may find some relief for chronic symptoms that have plagued you for years.

FURTHER READINGS “Carrageenan: How a ‘Natural’ Food Additive Is Making Us Sick.” Cornucopia Institute, Mar. 2013. Accessed Aug. 29, 2019. https://www.cornucopia.org/wp-content /uploads/2013/02/Carrageenan-Report1.pdf “Carrageenan Market by Type (Kappa, Lota and Lambda), by Application (Food Industry (Dairy, Meat, Beverages and Pet Food), Pharmaceutical Industry and Cosmetics Industry), by Grade (Refined Carrageenan and Semi-refined Carrageenan), by Seaweed Source (Gigartina, Chondrus, Iridaea and Eucheuma) and by Region—Global Growth, Trends, and Forecast to 2024.” Market Data Forecast, Oct. 2018. Accessed Aug. 29, 2019. https://www.marketdataforecast.com/market-reports/carrageenan -market “Carrageenan Market: Growth, Trends and Forecast (2019–2024).” MordorIntelligence. com. Accessed Aug. 29, 2019. https://www.mordorintelligence.com/industry-reports /global-carrageenan-market-industry “Carrageenan News Update.” FoodScienceMatters.com. Accessed Aug. 29, 2019. https:// www.foodsciencematters.com/carrageenan.html#poligeenan “Doubts Surface About Safety of Common Food Additive, Carrageenan.” Chicago Tribune, Mar. 18, 2013. Accessed Aug. 29, 2019. https://triumphtraining.com/blogs /blog/7559644-carrageenan-concerns-go-mainstream Fabian, R.J., et al. “Carrageenan-Induced Squamous Metaplasia of the Rectal Mucosa in the Rat.” Gastroenterology, Aug. 1973, 65(2), 265–276. Accessed Aug. 29, 2019. https://www.researchgate.net/publication/18448524_Carrageenan-Induced_Squamous _Metaplasia_of_the_Rectal_Mucosa_in_the_Rat “Facts and Figures 2019: US Cancer Death Rate Has Dropped 27% in 25 Years.” American Cancer Society, Jan. 8, 2019. Accessed Aug. 30, 2019. https://www.cancer.org/latest -news/facts-and-figures-2019.html McKim, J.M. “Food Additive Carrageenan: Part 1: A Critical Review of Carrageenan In Vitro Studies, Potential Pitfalls, and Implications for Human Health and Safety.”

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Critical Review of Toxicology, Mar. 2014, 44(3), 211–243. Accessed Aug. 29, 2019. https://www.ncbi.nlm.nih.gov/pubmed/24456237 “New Study Proves No Adverse Effects of Carrageenan in Human Cells.” International Food Additives Council news release, Aug. 10, 2016. Accessed Aug. 30, 2019. https://www .prnewswire.com/news-releases/new-study-proves-no-adverse-effects-of-carrageenan -in-human-cells-300311646.html Reinagel, Monica. “The Carrageenan Controversy.” Scientific American, Mar. 19, 2014. Accessed Aug. 30, 2019. https://www.quickanddirtytips.com/health-fitness /healthy-eating/know-your-nutrients/the-carrageenan-controversy Rustia, Mario, et al. “Lifespan Carcinogenicity Tests with Native Carrageenan in Rats and Hamsters.” Cancer Letters, Nov. 1980, 11(1), 1–10. Accessed Aug. 29, 2019. https:// www.sciencedirect.com/science/article/abs/pii/0304383580901226 Tobacman, J.K. “Review of Harmful Gastrointestinal Effects of Carrageenan in Animal Experiments.” Environmental Health Perspectives, Oct. 2001, 109(10), 983–984. Accessed Aug. 29, 2019. https://www.ncbi.nlm.nih.gov/pubmed/11675262 Tomarelli, Rudolph M., et al. “Nutritional Quality of Processed Milk Containing Carrageenan.” Journal of Agricultural Food Chemistry, May 1, 1974, 22(5), 819–824. Accessed Aug. 29, 2019. https://pubs.acs.org/doi/abs/10.1021/jf60195a037

Chocolate WHAT IS IT? The fermented, roasted, and ground seeds of the cacao tree produce the basis for the most popular candies in the United States and many countries around the world. Once the seeds are ground, the resulting cocoa mass is heated until liquid, forming a substance called chocolate liquor (though it has no alcohol content) that gets separated into cocoa butter and cocoa solids. These plant-based substances—liquor, butter, and solids—in varying proportions are used to create most of the chocolate we eat. Chocolate is not naturally sweet; the addition of dairy products and sugar takes the bitter cocoa to the next level in terms of pleasing taste, that satisfying “snap” as we bite into it, and the smooth, creamy mouthfeel consumers love, but this also boosts the calories significantly. Excessive consumption of chocolate plays a role in obesity, which in turn leads to diabetes, heart disease, some cancers, and even Alzheimer’s disease. Chocolate comes to consumers in candy bars, truffles, solid molded shapes, and as a flavoring or mix-in to cookies, cakes, other baked goods, ice cream, mocha and cocoa drinks, and sauces used in some cuisines. Varieties include dark chocolate, which contains between 50 and 90 percent cocoa solids; milk chocolate, which may contain between 10 and 50 percent cocoa solids; and white chocolate, which contains cocoa butter but no solids. More recently, cocoa and

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dark chocolate have been packaged as “therapeutic” doses with low to no sugar or dairy content. The growing category of premium-priced chocolate candies ranks chocolate according to the percentage of pure chocolate in the mix, as opposed to sugar, milk, butter, vegetable oil, and other ingredients. A 70-percent chocolate bar, for example, is a very dark chocolate that may taste bitter because of the dominance of pure cocoa over sugar. A Hershey’s milk chocolate bar, in contrast, may have just 10 percent chocolate, with sugar, milk, and other ingredients comprising the other 90 percent and giving the bar its characteristic creamy sweetness.

CURRENT CONSUMPTION STATISTICS AND TRENDS Chocolate is the number one candy consumed in the United States, dominating the confectionary industry with a 75 percent share of the candy market— and its share continues to grow as consumer interest in organic and premium chocolates increases. Sales of chocolate dominate the market at $11.2 billion in the year ended July 15, 2018, according to Food Business News. This represents a 0.7 percent increase over 2017. Some $5.3 billion of this extravagant number represents sales of larger items, greater than 3.5 ounces in weight—presumably large bars or bags containing multiple candies and molded chocolates like Easter bunnies. (For reference, the single-serving bag of plain M&Ms® at a checkout counter is 1.69 ounces, while a two-piece Reese’s® Peanut Butter Cups package weighs 1.5 ounces.) During the COVID-19 pandemic, the National Confectioners Association reported that sales of chocolate grew 5.5 percent, with much of this in premium chocolate—a niche market that grew by 12.5 percent. The confectionary industry produces a steady stream of new variations on old favorites to maintain this momentum. M&Ms’ coated chocolate candies, for example, only came in plain and peanut varieties for decades, but now include more than thirty varieties, with seasonal flavors like white chocolate candy corn and hot cocoa and specialties like raspberry and crunchy espresso. Dove® chocolate, the premium brand made by Mars Inc., now features more than fifty varieties, from bite-sized squares and bars to fancy truffles and a line of coated ice cream products.

NUTRITIONAL INFORMATION Cocoa butter contains fat, more than half of which is saturated fat. This has the effect of increasing total cholesterol in the human body by boosting the levels of LDL cholesterol, also known as “bad” cholesterol. Nearly all chocolate products, with the notable exceptions of unsweetened cocoa and baking chocolate, contain considerable amounts of sugar, which are implicated in the development of dental cavities, obesity, high blood pressure, diabetes, and coronary artery disease.

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Both cocoa liquor and cocoa butter contain compounds known as flavanols, which are also found in a number of other plant-based foods. The flavanols found in these cocoa products include catechins, which are the only flavanols in chocolate that do not bind to sugar, making them easier for the body to absorb. The more prevalent flavanol in chocolate is epicatechin, which can be classified as an antioxidant and which may have positive effects on human blood circulation and cognitive activity when administered in large doses (more on this later). Depending on the brand and variety, additional ingredients in chocolate can include some form of lecithin, a thickening agent; vanilla extract (made from vanilla beans) or vanillin, a cheaper alternative made from wood pulp and paper industry by-products; high-fructose corn syrup; corn syrup solids; partially hydrogenated oils that add trans fats; artificial flavors and colors, produced using synthetics; “emulsifiers” that replace some of the pricier cocoa butter; and preservatives like potassium sorbate. Some chocolate candy substitutes sugar alcohols (which are neither sugar nor alcohol and are detailed elsewhere in this book) to reduce or eliminate the overall sugar content.

HISTORY The first signs of cultivation of cocoa beans appeared in 1500 BC, when the native Olmecs in Mesoamerica, living in what is now south-central Mexico, turned the wild-growing beans into a domestic crop. The Olmecs introduced the Mayan civilization to the beans somewhere around 300 BC; the Mayans ground the beans and made them into an unsweetened drink consumed only by those of the elite class. As the Mayans moved northward from South America into Mesoamerica between AD 600 and 1000, they established cocoa plantations in the Yucatan and used the beans both for consumption and as currency. In the 1200s, the Maya began to trade with the Aztecs, who drank the bitter cocoa liquid and decided it needed additional flavoring. These creative newcomers to cocoa added cinnamon, pepper, vanilla, and chiles, and the drink quickly gained popularity with the Aztec elite. The Aztecs advanced this exclusivity by restricting the sharing of “cacahuatl” with anyone but the most noble among them and even impose the first tax on cocoa beans. They believe that one of their pantheon of gods, Quetzalcoatl, gave them the beans—and in 1519, when Spanish explorer Hernando Cortez arrived on their shores, they mistook him for Quetzalcoatl and shared the beans with him. As the Aztecs used cocoa beans as money, Cortez saw an opportunity for massive wealth and built a cocoa plantation in Spain’s name, conquering the Aztecs within the decade and taking their cocoa beans and chocolate recipes back to the Spanish royal court. King Charles V also realized the opportunity this new food provided, so he assigned the processing of the nation’s imported cocoa beans to the monasteries, where it remained a closely guarded secret for nearly a century. Here some wise Spaniard substituted sugar for the chiles and other spices in the traditional drink, turning cocoa into the chocolate we know.

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Such a confection could not stay under wraps forever, and in the early 1600s, a traveler from Italy discovered it and brought it home with him. Soon demand in Italy became so great that “cioccolatieri” opened all over the country, and the rich drink’s popularity spread throughout Europe. By 1700, chocolate found its way into pastries, and solid bars of chocolate—not the creamily blended kind we know now, but with a grittier texture—became an exciting new treat. Chocolate circled back to the Americas, arriving first in Boston in 1712 as an import from Europe. The turning point, however, came in 1795, when Dr. Joseph Fry used a steam engine to grind cocoa beans, moving the production of chocolate from an artisan activity to a machine-driven enterprise. In 1847, Fry’s grandson, Francis, mixed cocoa powder with cocoa butter and discovered that the resulting paste could be molded into figures and bars, and while these still had a grainy texture and lacked the smoothness we now expect from chocolate bars, he nonetheless opened up a new category in the market. Other innovators including the Cadbury brothers in England, Ghirardelli in San Francisco, and Daniel Peter—the neighbor of Henri Nestlé—perfected the process and added their own ingenuity to create new “eating chocolates.” The Swiss developed a method known as “conching” to produce a smoother, creamier chocolate, and this modern chocolate became a standard throughout the industry. In 1895, Milton S. Hershey created the first mass-produced chocolate bar that virtually anyone could afford, and he met with such success that he opened his model factory town, Hersheyville, in Pennsylvania just five years later. Today chocolate reaches every part of the world and is available to anyone, and it features flavors that know no bounds, including some that hearken back to the Aztecs’ chile-and-cinnamon concoction. The Ivory Coast in Africa produces the largest share of the world’s cocoa beans, while the Netherlands leads the industry in grinding cocoa and exporting it to manufacturers on six continents.

THE CONTROVERSY Scientists have put considerable effort into attempting to prove that chocolate, especially dark chocolate, may have a beneficial effect on health. This effort may appear on the surface to be driven by humanity’s need to justify the massive quantities it consumes of this high-fat, high-sugar confection. The truth, however, is quite different: Most of this research has originated with chocolate manufacturers looking to increase profits in the face of declining sales of milk chocolate, which generally contains more fat and sugar than its dark counterpart. Many studies about the benefits of flavanols, plant nutrients that appear naturally in cocoa, have been conducted or supported by the research laboratories at Mars Inc., one of the world’s largest manufacturers of chocolate and chocolate products. Flavanols are a class of flavonoid, antioxidants that can protect the body’s cells from free radicals—substances that form in the normal course of living, but that can damage healthy cells and cause a number of diseases. Mars conducts “the world’s largest program studying the dietary effects of cocoa

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flavonoids,” according to the company’s website. Obviously, findings that chocolate may be beneficial to health can be of great benefit to the company, though Mars itself cautions, “Before you stock up on chocolate, remember these benefits come from compounds in cocoa pods, little of which can be found in your typical chocolate bar.” Mars has conducted or participated in more than 160 studies to date on chocolate’s health benefits, including many of the studies published in peer-reviewed scientific journals. In 2006, a study supported by Mars and conducted at Harvard Medical School and Brigham Women’s Hospital in Boston determined that ingestion of cocoa rich in flavanols can have a positive effect on health. Eating specific amounts of cocoa served to improve circulation in older adults by dilating blood vessels, which in turn improved their cognitive function. While the data was preliminary, the researchers noted, “The prospect of increasing cerebral function with cocoa flavanols is extremely promising.” In 2009, the journal Circulation published a study that examined an isolated population of Kuna natives living on an island off the coast of Panama. The Kunas consumed ten times more cocoa than their counterparts on the mainland, and while this island population maintained low blood pressure throughout their lives, their relatives in Panama developed normal age-related hypertension. This discrepancy led researcher R. Corti and colleagues to propose that the flavanols in cocoa served to keep blood pressure low. Many studies attempted to prove this hypothesis, including randomized, double-blind studies that limited the possibility of placebo effect—that is, participants realizing that they were eating chocolate and deliberately or inadvertently skewing the resulting health effects. Others are population-based studies, in which existing data is used to draw conclusions about large groups of people. One of these, conducted in Sweden beginning in 1998, examined how much chocolate (along with ninety-five other foods) more than 33,000 healthy women consumed. Based solely on this survey—which asked these women to recollect a year’s worth of chocolate consumption, rather than tracking it as it happened— the Swedish team observed how many of the women had a stroke from 1998 to 2008. They determined that the women who ate the most chocolate had the fewest strokes, leading them to conclude that high chocolate consumption actually protected the women against stroke. The fact that the study was based on memory of past events, providing the researchers with no opportunity to control for hundreds of other variables, reminds us that correlation does not necessarily mean causation. A series of studies have tested the hypothesis that cocoa’s flavanols may interfere with the development of colon cancer. These studies involved in vitro (cell cultures in a laboratory) and in vivo (tests on animals, usually mice) models, not human beings, and subsequent studies involving humans had mixed result in finding a correlation between cocoa consumption and a reduced risk of colorectal cancer. In fact, a number of studies found that chocolate consumption actually increased the risk of colon cancer in humans, because of the effect of the high refined carbohydrate and sugar intake on insulin and IGF-1, a cancer catalyst.

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A 2014 book by neuroscientist Will Clower titled Eat Chocolate, Lose Weight recommended that a single square of dark chocolate allowed to melt on the tongue twenty minutes before a meal had the effect of reducing appetite for a meal by as much as half. Despite the very specific limitations Clower detailed in his book for an appropriate use of dark chocolate as an appetite suppressant, the book’s title and the resulting media sound bites did not convey this message in its entirety to the public. Instead, chocolate as a weight loss tool became part of the new definition of dark chocolate as a “superfood,” supposedly loaded with nutrients and disease-fighting agents that chocolate simply does not contain. These are just a few of the studies that have led the news media to announce that “Chocolate is good for you!” A 2012 article in the news site The Daily Beast, for example, lists eleven ways that chocolate—any chocolate, regardless of flavanol content or grams of sugar—improves health, from decreasing the risk of heart attack and stroke to preventing cancer and diabetes, as well as helping consumers do math and actually making a person lose weight. A 2018 article on the Healthline website calls dark chocolate “one of the best sources of antioxidants on the planet,” a claim that is patently false according to virtually every study about chocolate and flavanols. Based on the previous decade’s research examining the health benefits of chocolate, the European Food Safety Authority (EFSA) seemed satisfied that at least some of the claims had merit. In 2013 Barry Callebaut, an ingredients supplier in Europe, won approval from the EFSA of his claim that 2.5 g of dark chocolate per day that contained 200 mg of cocoa flavanols “contributes to normal blood circulation by helping to maintain the elasticity of the blood vessels.” Callebaut licensed this claim to the few chocolate manufacturers that could prove their chocolate contained the requisite levels of flavanols, but food scientists at three German universities produced research in 2016 that refuted it. They noted that even the chocolates that could make the case that they had 200 mg of flavanols did not necessarily have 100 mg of epicatechin, the only flavanol in cocoa that actually affects blood pressure. A quantity of cocoa that contains 200 mg of flavanols usually has only about 46 mg of epicatechin, the researchers reported. They, in turn, cited several studies in which quantities of epicatechin lower than 100 mg had no effect on blood pressure. Some researchers have concluded that certain brands of dark chocolate with high cocoa content do indeed lower participants’ blood pressure by a statistically significant 3.1 points (or less). While this may be good news for chocolate lovers, using nothing but dark chocolate to control hypertension would be impractical and ineffective for most people with high blood pressure, as the fat and sugar content contributes to weight gain, which leads to heart disease and diabetes. The preparation of mass-produced chocolate can have a limiting effect on its health benefits as well. Many products containing cocoa powder or cocoa liquor go through Dutch processing to improve flavor, color, and texture, during which they are mixed with alkali. This makes the chocolate darker (Oreo cookies, e.g., use heavily alkalized chocolate) and reduces its bitterness. Alkali also makes cocoa powder easier to disperse in liquids, so products like instant hot

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chocolate and unsweetened baking cocoa often have been processed with alkali. In chemical terms, chocolate is highly acidic, and alkalization adds a base to cocoa powder, effectively neutralizing its chemical reaction in baking and cooking. In the United States, products containing alkalized chocolate have to say so on their packaging. The thing about alkali, however, is that it reduces the amount of flavanols in the chocolate. A 2008 study measured the flavanol content, antioxidation efficiency, and total polyphenol content of cocoa processed without alkali, as well as lightly, medium, and heavily alkalized cocoa. Researcher K.B. Miller and colleagues discovered that natural cocoa had the highest total flavanols at 34.6 ± 6.8 µg/g. This dropped significantly as more alkali was added: The lightly alkalized cocoa retained 13.8 ± 7.3 µg/g, the medium alkalized cocoa had just 7.8 ± 4.0 µg/g, and the heavily alkalized powder measured 3.9 ± 1.8 µg/g of flavanols. As with most processed foods, chocolate becomes less nutritious even as it becomes more flavorful. So how much is a therapeutic “dose” of dark chocolate? With so many variables affecting the amounts of epicatechin per bar, there is no easy way for the average consumer to judge this. Chocolate bars generally do not have this kind of technical information on the wrapper, so some significant research may be required before we can make the best choice from hundreds of varieties. If chocolate lovers find this a disappointing result of all the promised benefits, keep in mind that other foods have the same flavanol content as an ounce of dark chocolate without the added fat and sugar: tea, cranberries, peanuts, onions, apples, and red wine, for example. Alternately, Mars Inc. has used its research to produce its Cocoa Via line of products, including cocoa extract capsules and premeasured powder packets (to be diluted in water, yogurt, or tea) with 375 mg of flavanols per serving. Those looking to rationalize their choice of delicious chocolate over other methods of lowering blood pressure and improving overall health—such as diet and exercise—may find that their favorite treat does not provide the therapeutic benefits they were hoping to obtain. As the adage goes, “If it looks too good to be true, it probably is.”

FURTHER READINGS “A Chocolate Timeline: Follow One of Man’s Favorite Foods.” The Nibble, May 2010. Accessed May 21, 2019. https://www.thenibble.com/reviews/main/chocolate/the-his tory-of-chocolate.asp Bonetti, Francesco, et al. “Nootropics, Functional Foods and Dietary Patterns for Prevention of Cognitive Decline.” Nutritional and Functional Foods for Healthy Aging, Watson, Ronald Ross, ed. London, UK: Academic Press, Elsevier, 2017. Accessed May 20, 2019. https:// www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science /flavanols EFSA Panel on Dietetic Products, Nutrition and Allergies. “Scientific Opinion on the Modification of the Authorisation of a Health Claim Related to Cocoa Flavanols and

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Maintenance of Normal Endothelium-Dependent Vasodilation Pursuant to Article 13(5) of Regulation (EC) No 1924/2006 Following a Request in Accordance with Article 19 of Regulation (EC) No 1924/2006.” EFSA Journal, May 5, 2014. Accessed May 25, 2019. https://efsa.onlinelibrary.wiley.com/doi/10.2903/j.efsa.2014.3654 Egan, Brent M., et al. “Does Dark Chocolate Have a Roll in the Prevention and Management of Hypertension? Commentary on the Evidence.” Hypertension, June 2010, 56(6). Accessed May 22, 2019. https://www.ahajournals.org/doi/full/10.1161/HYPER TENSIONAHA.110.151522 Fisher, Naomi D.L., et al. “Cocoa Flavanols and Brain Perfusion.” Journal of Cardiovascular Pharmacology, June 2006, 47, S210–S214. Accessed May 25, 2019. https://journals.lww .com/cardiovascularpharm/Fulltext/2006/06001/Cocoa_Flavanols_and_Brain_ Perfusion.17.aspx Gunnars, Kris. “7 Proven Health Benefits of Dark Chocolate.” Healthline, June 25, 2018. Accessed May 25, 2019. https://www.healthline.com/nutrition/7-health-benefits-dark -chocolate “Heart Healthy Benefits of Chocolate.” Cleveland Clinic. Accessed May 22, 2019. https:// my.clevelandclinic.org/health/articles/16774-heart-healthy-benefits-of-chocolate Heller, Jake. “11 Reasons Chocolate’s Good For You.” The Daily Beast, Mar. 28, 2012. Accessed May 25, 2019. https://www.thedailybeast.com/11-reasons-chocolates-good-for-you Larsson, Susanna C., et al. “Chocolate Consumption and Risk of Stroke in Women.” Journal of the American College of Cardiology, Oct. 18, 2011, 58(17), 1828–1829. Accessed May 25, 2019. https://www.sciencedirect.com/science/article/pii/S0735109 711028440?via%3Dihub Latif, R. “Chocolate/Cocoa and Human Health: A Review.” Netherlands Journal of Medicine, Mar. 2013, 71(2), 63–68. Accessed May 20, 2019. http://www.njmonline.nl /getpdf.php?id=1269 Martin, Maria Angeles, et al. “Preventive Effects of Cocoa and Cocoa Antioxidants on Colon Cancer.” Diseases, Mar. 2016, 4(1). Accessed May 26, 2019. https://www.ncbi .nlm.nih.gov/pmc/articles/PMC5456306/ Miller, K.B., et al. “Impact of Alkalization on the Antioxidant and Flavanol Content of Commercial Cocoa Powders.” Journal of Agricultural and Food Chemistry, Sept. 24, 2008, 56(18), 8527–8533. Accessed May 21, 2019. https://www.ncbi.nlm.nih.gov /pubmed/18710243 Nieburg, Oliver. “Healthy Chocolate: EU Cocoa Flavanol Health Claim ‘Should Be Revised,’ Say Researchers.” Confectionary News, July 5, 2016. Accessed May 22, 2019. https://www.confectionerynews.com/Article/2016/07/06/EU-cocoa-flavanol-health -claim-should-be-revised-Study “North America Confectionery Market—Segmented by Product Type, Distribution Channel and Geography—Growth, Trends, and Forecast (2018–2023).” Research and Markets, May 2018. Accessed May 20, 2019. https://www.researchandmarkets.com /research/74brv3/the_north_america?w=4 Watrous, Monica. “State of the Industry: Confectionary.” Food Business News, Dec. 17, 2018. Accessed May 20, 2019. https://www.foodbusinessnews.net/articles/12971 -state-of-the-industry-confectionery Watrous, Monica. “State of the Industry: Confectionary.” Food Business News, Dec. 15, 2020. Accessed April 13, 2021. https://www.foodbusinessnews.net/articles/17383-con fectionery-industry-boosted-by-low-sugar-innovation

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Coconut Oil WHAT IS IT? Coconut oil comes from the flesh of the coconut. Products fall into two general categories: refined and unrefined or virgin. Refined varieties are extracted from the dried coconut meat (also known as copra) and usually have no odor or taste. This is because the refined versions have been processed more aggressively, filtered to remove any impurities, and treated to lighten their color or to remove coconut scent and flavor. Chemicals including hexane may be required to help extract the oil from the coconut meat. “Virgin” or unrefined coconut oil is pressed from the fresh coconut meat and may retain more coconut aroma and taste than refined versions. Virgin varieties contain no added chemicals. Oils cannot be considered “whole” foods, as the very definition of oil dictates that it be extracted from plant material. Some coconut oils have been labeled “whole kernel” by their manufacturers, a moniker that indicates that the brown inside skin of the coconut remained on the nut meat during the oil extraction process. Whole kernel oils retain more flavor and nutrients, making them preferable in some applications, while some consumers prefer the appearance and gentler scent of white kernel coconut oil, the product of coconuts with the inside skin removed. Most brands extract coconut oil using the expeller-pressed or cold-pressed methods. Expeller pressing uses a machine at high pressure to extract the oil from the meat and usually involves heating the meat to 120°F or above. Cold-pressed coconut oil uses the same process but without the heat and may allow the oil to retain more of its nutrients. A third process, centrifuging, begins with removal of the coconut milk from the meat and then involves removal of the shell and spinning the meat in a centrifuge, crushing the remaining meat to a fine paste. This process separates the meat from the oil remaining in it. The many steps and specialized machinery involved make this a particularly expensive process, so centrifuged coconut oil tends to be pricier than expeller-pressed or cold-pressed varieties. Coconut oil can be used in cooking (though at relatively low temperatures— it will begin to smoke between 350°F and 400°F), but its high saturated fat content requires that its use as a cooking oil be limited as part of a healthy diet. Based on its flavor, its high saturated fat content, and its overall popularity with consumers, many snack manufacturers use coconut oil in products including cookies, cakes, cupcakes, ice cream, and yogurt. The cosmetics industry has embraced its power as a frizz smoother, lubricant, and moisturizer, adding it to all kinds of skin and hair care products, from facial masks to high-end creams and conditioners.

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CURRENT CONSUMPTION STATISTICS AND TRENDS The firm Market Research Future reported in May 2019 that the coconut oil market is expected to reach $8.4 billion by 2025. According to MarketWatch, the global market for virgin coconut oil (VCO) alone reached $650 million in 2018 and is expected to continue to grow at 2.3 percent annually through 2025. The U.S. consumption hit a peak in 2009 with 598,000 megatons sold, according to the U.S. Department of Agriculture, but it declined nearly 19 percent the following year. In recent years, consumption has dropped to about 445,000 megatons. Coconut oil has lost some of its luster as the American Heart Association (AHA) issued a presidential advisory in 2017 to avoid saturated fat—coconut oil is up to 90 percent saturated fat—and replace it with polyunsaturated vegetable oil. Other studies suggest that there is not enough evidence to conclude that saturated fat provides a direct route to heart disease or that eliminating it entirely will protect against heart problems. (See Saturated Fat later in this book.)

NUTRITIONAL INFORMATION Coconut oil is a particularly fatty fat, surpassing palm kernel oil at 82 percent saturated fat, according to the AHA report. Some reports say that coconut oil’s saturated fat content is as high as 90 percent. This is the highest saturated fat content of any of the commonly used oils, a fact that led the AHA to recommend that it be decreased in any healthy diet. The rest of coconut oil’s composition is small amounts of polyunsaturated and monounsaturated fat, the part considered “good” fat (or at least not harmful fat). Together, they add up to 100 percent fat, a good reminder that coconut oil is purely fat. The oil does not contain any cholesterol, though it plays a role in creating LDL cholesterol in people who consume it. Tiny amounts of vitamins may be present in some products, but they are not enough to make it to the nutrition facts label. Some versions of refined coconut oil may contain partially hydrogenated unsaturated fats, a processed ingredient that acts as a preservative and keeps solidified oil from melting in a warm environment. Partially hydrogenated fats are trans fats, the most destructive fats to the human body. Read the label before purchasing any coconut oil to be sure that it does not contain these harmful ingredients.

HISTORY References to the fruit that would eventually be named the coconut can be found in texts dating back to the fifth century AD. Use of the oil extracted from

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the skin and meat predates recorded history, beginning to appear in the journals of explorers and in stories from far eastern and southern Asia in the ninth century. People who had access to the oil used it as an aid to healing wounds, as a massage oil for sore muscles, in making candles, and as a skin lotion and hair restorative. Pacific island dwellers believed the oil could protect against illness, cure ailments, encourage bone growth, and clear up acne. A tree of tropical climates, the coconut palm became a cultivated crop in India, Sri Lanka, the Philippines, Malaysia, Indonesia, and Papua New Guinea at least two thousand years ago. Its white flesh served as a food staple, and the water or “milk” that naturally resides inside provided additional nourishment and food flavoring. The large fruit had many names before the 1700s, when the Portuguese finally labeled it “coco,” using their language’s word for head. In the late 1800s, European businesses saw value in coconut oil as a product, because of its versatility as an ingredient in soap and as a cooking aid. They used their land holdings in Southeast Asia, the southern Pacific islands, and the Caribbean islands to build plantations for coconut production, creating a new market in Europe and the United States for the exotic oil. The arrival of World War II put an end to this trade temporarily, curtailing the availability of this as well as a number of other oils pressed from tropical plants. (This turned out to be a lucky break for soy-based oils, as soybeans could be grown in cooler, drier climates like the American Great Plains.) When the war ended, soybean and vegetable oils had replaced coconut, palm, and olive oil in cooking, and while coconut oil producers scrambled to get back the market share they’d lost, they met with a new obstacle: the science of saturated fat. In the 1950s, Ancel Keys, a well-known nutrition scientist, determined that too much saturated fat in the human diet correlated directly with high cholesterol levels. Other researchers tested this hypothesis and found a direct link between saturated fat and cholesterol, though these findings were disputed by coconut oil producers. People in the south seas who had used coconut oil in cooking for centuries did not develop this high cholesterol, they said, because they also ate plenty of fish rich in omega-3 fatty acids. The combination of coconut oil and fish actually produced better health, they claimed. The research that coconut oil producers questioned may also have involved hydrogenated oil, which is loaded with trans fats—so these additional, destructive fats may have been the actual culprit that caused the spikes in cholesterol. This early research and a number of more recent studies have kept the question open of whether coconut oil has a healthful or health-damaging effect. The now decades-old controversy has not reached a definitive conclusion, but coconut oil has come to the fore as a key wellness ingredient among those looking for naturopathic remedies for common ailments. Most of these people cite studies that indicate that elements of coconut oil—lauric acid in particular— have a beneficial effect against a range of diseases, from osteoporosis to colon cancer.

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THE CONTROVERSY The multibillion-dollar coconut oil industry has done a remarkable job of marketing its products as healthy, so much so that in a recent survey, 72 percent of Americans called coconut oil a “healthy” food, while only 37 percent of nutritionists agreed. This achievement may delight shareholders, but it flies in the face of careful research completed as far back as 1995, when a team at the Department of Human Nutrition at the University of Otago in New Zealand compared the effects of coconut oil, butter, and safflower oil in a small cohort of twenty-eight people with slightly elevated cholesterol. The subjects all followed the same diets for six weeks at a time, first using coconut oil as the primary fat, then butter, and finally safflower oil. The researchers found that butter elevated LDL cholesterol significantly, and coconut oil came in a very close second. Safflower oil did not elevate the subjects’ total or LDL cholesterol. The T.H. Chan School of Public Health at Harvard University provides information that helps us understand the difference between manufacturers’ marketing claims and research results. Saturated fats can be sorted into three distinct types: short-, medium- (MCTs), and long-chain triglycerides (LCTs; fatty acids). LCTs get stored in the body’s fat tissue, often taking up residence and increasing body weight. MCTs, however, go to the liver, where they are quickly metabolized so the body can use them for energy. Studies using a special formulation of coconut oil high in MCTs determined that the coconut oil could promote a feeling of fullness sooner in a meal and that it did not get stored as fat in the body. This formulation, however, is not the coconut oil sold in stores as food. The coconut oil in supermarkets contains lauric acid as its predominant saturated fat; lauric acid sometimes acts like a long-chain fatty acid and gets stored in the body’s fat cells and sometimes acts like an MCT and gets converted to energy. VCO also contains capric and caprylic acids, two additional MCTs, but in much smaller amounts than lauric acid. These, accompanied by smaller amounts of myristic and palmitic triglycerides (which are long chain), make up virtually all of the fat in coconut oil. “It’s important not to draw conclusions about the benefits of coconut oil based on studies with oils called medium-chain triglyceride (MCT) oil,” the Mayo Clinic warns. This has not stopped coconut oil manufacturers from claiming that their products can assist in weight loss, based on the action of MCTs in experiments with this manipulated oil. These claims are based on studies that tested MCTs, not coconut oil specifically (in fact, coconut oil is not mentioned in the studies), and found that men who consumed more MCTs than LCTs expended more energy and lost more fat tissue than those who ate LCTs (St-Onge, 2003; Dulloo, 1996). One of the lead researchers on such a study, Marie-Pierre St-Onge, PhD, at Columbia University, was quick to make this clarification in the popular press. “There’s strong data on the weight loss properties of MCT oil in general, but not as much for coconut oil specifically,” she explained to a writer at Woman’s Day. “Coconut oil is only 13.5 percent of purified MCT. To get 10g [grams] of MCT,

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you need to eat 80g coconut oil. 80g of any oil in a single day is a lot of oil, especially coconut oil, which is so high in saturated fat” (Natale and Lee, 2019). Small studies have borne out this conflict between consuming enough coconut oil to have an impact on weight loss and maintaining a heart-healthy diet. A 2017 study involving thirty-two volunteers in Thailand had each of the participants take 15 mL of VCO twice daily (a total of 26 g of saturated fat) or the same amount of a control solution for eight weeks. At the end of the trial, the participants who had taken VCO saw an increase in HDL (good) cholesterol. “Daily consumption of 30 mL VCO in young healthy adults significantly increased highdensity lipoprotein cholesterol,” the researchers reported in Evidence-Based Complementary Alternative Medicine (Chinwong et al., 2017). The short-term study did not delve into the potential issues created by ingesting so much saturated fat on a daily basis, however; the AHA recommends no more than 13 g of saturated fat each day or about 5 percent of a person’s total caloric intake. A 2009 study on forty women with abdominal obesity placed these women on a strict diet and an exercise program that involved walking for fifty minutes daily and also gave them supplements containing either 30 mL of coconut oil or soybean oil. The group that received coconut oil lost more belly fat and saw an increase in HDL, while both groups experienced some weight loss. So far, all of the studies conducted on coconut oil have been short term and with small groups of people, and they have incorporated coconut oil into a larger and more comprehensive diet and exercise program. The result? “There is no evidence that coconut oil will have a beneficial effect on weight loss if you simply add it to your diet,” the Mayo Clinic reports. Much more comprehensive, longterm research will be required to understand if this oil, with its sky-high saturated fat content, may actually have a positive effect on the human body. A detailed review of studies to date on coconut oil’s effects on weight loss, heart disease, and other illnesses appeared in Nutrition Bulletin in 2016. The authors note: Recipe books, advertisements and some journal articles are claiming that coconut oil is a cure-all product that has weight reduction, cholesterol-lowering, wound healing and immune system, energy and memory-boosting effects and can be used to treat Crohn’s disease, irritable bowel syndrome, thyroid conditions, diabetes, and well as Alzheimer’s and Parkinson’s diseases.

After a careful enumeration of the studies to date and their relative credibility, the paper concludes, Due to existing knowledge regarding saturated fatty acids and heart disease, evidence . . . suggesting that coconut oil raises plasma lipids and a lack of large, wellcontrolled human studies published in peer-reviewed journals demonstrating clear health benefits of coconut oil, frequent use of coconut oil should not be advised. (Lockyer and Stanner, 2016)

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In 2017, the journal Cell Death Discovery published a study that indicates that lauric acid may prompt the death of colon, endometrial, and breast cancer cells. “Collectively, our findings may pave the way to better understand the anticancer action of [lauric acid], although additional studies are warranted to further corroborate its usefulness in more comprehensive therapeutic approaches,” the researchers concluded (Lappano et al., 2017). Until such long-term controlled studies emerge, coconut oil’s most effective uses continue to be topical, as an aid to complexion and a conditioner to restore damaged hair. If it does have an effect against any disease, much more research will be required to determine the delivery method, dosage, and other protocols that may be involved in using components of coconut oil in treatment. Simply eating more of it is not medically significant against cancer or any other illness.

FURTHER READINGS Assunça¯o, Monica L., et al. “Effects of Dietary Coconut Oil on the Biochemical and Anthropometric Profiles of Women Presenting Abdominal Obesity.” Lipids, July 2009, 44(7), 593–601. Accessed Sept. 3, 2019. https://link.springer.com/article/10.1007 /s11745-009-3306-6 Chinwong, Surarong, et al. “Daily Consumption of Virgin Coconut Oil Increases HighDensity Lipoprotein Cholesterol Levels in Health Volunteers: A Randomized Crossover Trial.” Evidence-Based Complementary Alternative Medicine, Dec. 4, 2017. Accessed Sept. 3, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5745680/ “Coconut Oil for Weight Loss: Does It Work?” Mayo Clinic. Accessed Sept. 3, 2019. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/coconut-oil -and-weight-loss/art-20450177 “Coconut Oil Market Research Report-Global Forecast Till 2025.” Market Research Future, Feb. 2019. Accessed Sept. 3, 2019. https://www.marketresearchfuture.com /reports/coconut-oil-market-7452 Cox, C., et al. “Effects of Coconut Oil, Butter, and Safflower Oil on Lipids and Lipoproteins in Persons with Moderately Elevated Cholesterol Levels.” Journal of Lipid Research, Aug. 1995, 36(8), 1787–1795. Accessed Sept. 3, 2019. https://www.ncbi.nlm .nih.gov/pubmed/7595099?dopt=Abstract Dulloo, A.G; Fathi, M.; Mensi, N.; and Girandier, L. “Twenty-Four-Hour Energy Expenditure and Urinary Catecholamines of Humans Consuming Low-to-Moderate Amounts of Medium-Chain Triglycerides: A Dose-Response Study in a Human Respiratory Chamber.” European Journal of Clinical Nutrition, Mar. 1996, 50(3), 152–158. Accessed Sept. 3, 2019. https://www.ncbi.nlm.nih.gov/pubmed/8654328 Lappano, Rosamaria, et al. “The Lauric Acid-Activated Signaling Prompts Apoptosis in Cancer Cells.” Cell Death Discovery, 2017, 3, 17063. Accessed Sept. 4, 2019. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5601385/ Lockyer, S.; and Stanner, S., “Coconut Oil—A Nutty Idea?” Facts Behind the Headlines, Nutrition Bulletin, Feb. 16, 2016. Accessed Sept. 4, 2019. https://onlinelibrary.wiley .com/doi/full/10.1111/nbu.12188

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Natale, Nicol; and Lee, Byron P. “Can Coconut Oil Help with Weight Loss? Experts Break It Down.” Woman’s Day, Feb. 8, 2019. Accessed Sept. 3, 2019. https://www.womans day.com/health-fitness/a58976/coconut-oil-weight-loss/ “The Nutrition Source: Coconut Oil.” T.H. Chan School of Public Health, Harvard University. Accessed Sept. 3, 2019. https://www.hsph.harvard.edu/nutritionsource /food-features/coconut-oil/ Quealy, K.; and Sanger-Katz, M. “Is Sushi ‘Healthy’? What About Granola? Where Americans and Nutritionists Disagree.” New York Times, July 5, 2016. Accessed Sept. 3, 2019. https://www.nytimes.com/interactive/2016/07/05/upshot/is-sushi-healthy-what-about -granola-where-americans-and-nutritionists-disagree.html?_r=0%20Y. Sacks, Frank M., et al. “Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association.” Circulation, June 15, 2017, 136(3). Accessed Sept. 3, 2019. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000510 St-Onge, M.P.; and Jones, P.J. “Greater Rise in Fat Oxidation with Medium-Chain Triglyceride Consumption Relative to Long-Chain Triglyceride Is Associated with Lower Initial Body Weight and Greater Loss of Subcutaneous Adipose Tissue.” International Journal of Obesity and Related Metabolic Disorders, Dec. 2003, 27(12), 1565–1571. Accessed Sept. 3, 2019. https://www.ncbi.nlm.nih.gov/pubmed/12975635 “Understanding Coconut Oil.” Kimberton Whole Foods. Accessed Sept. 3, 2019. https:// www.kimbertonwholefoods.com/decoding-coconut-oil/#.XW6qOC3MwWo “United States Coconut Oil Domestic Consumption by Year.” IndexMundi. Accessed Sept. 3, 2019. https://www.indexmundi.com/agriculture/?country=us&commodity=co conut-oil&graph=domestic-consumption “Virgin Coconut Oil Market Size 2019, Global Trends, Industry Share, Growth Drivers, Business Opportunities and Demand Forecast to 2025.” MarketWatch, Apr. 3, 2019. Accessed Sept. 3, 2019. https://www.marketwatch.com/press-release/virgin-coconut -oil-market-size-2019-global-trends-industry-share-growth-drivers-business-opportuni ties-and-demand-forecast-to-2025-2019-04-03

Cruciferous Vegetables WHAT ARE THEY? Plants in the family Cruciferae are part of the large category of cruciferous vegetables. Generally, these include leafy greens like arugula, bok choy, broccoli, broccoli rabe, Brussels sprouts, cabbage, cauliflower, Chinese broccoli, Chinese cabbage, collard greens, daikon, garden cress, horseradish, kale, kohlrabi, komatsuna, mizuna, mustard leaves, radish, rutabaga, tatsoi, turnip roots and greens, wasabi, and watercress.

CURRENT CONSUMPTION STATISTICS AND TRENDS In 2017, the last year for which statistics are available, the world produced 71.45 million metric tons of cabbages and other leafy green vegetables in the

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cruciferous category. In addition, farms produced twenty-six million metric tons of cauliflower and broccoli. Cruciferous vegetables represented a $13.84 billion market in the United States alone in 2017. California surpasses all other states in fresh vegetable output, according to the USDA, accounting for 60 percent of vegetable production in the country. As large a market as this is, however, the U.S. growers have seen a decline in the fresh vegetable market in 2018 and 2019, down 9 percent in 2018 alone. Much of this comes from planting less acreage and smaller harvests, in part because of record heat throughout the growing season. Vegetable Growers News reported that the decline in production coincides with lower monthly rainfall and higher temperatures, both of which can be attributed to climate change. The difficulty in using the complicated H-2A guest agricultural work program, which allows immigrants to enter the country temporarily to work on industrial farms, also has hindered farms’ ability to harvest crops in a timely manner. While vegetable production fell in 2017 to its lowest point in seventeen years, consumer demand remains high—even in the face of outbreaks of foodborne illness found in leafy green vegetables (specifically romaine, which is not in the cruciferous family). Bagged salads, packaging of pre-cut fresh vegetables, and microwaveable bags of vegetables have spurred purchase rates, even though these convenience products are more expensive. The growth in organic vegetable availability has also influenced the demand.

NUTRITIONAL INFORMATION These vegetables earn their “superfoods” title for good reason: They are packed with vitamins and minerals the human body needs to function properly. One three-fourth-cup serving of broccoli, for example, contains more than 20 percent of the recommended daily amount of folate, the B vitamin required for cell division and the production of DNA. It also provides plenty of vitamin C, which may protect cells from cancer-causing free radicals and strengthens the immune system. Leafy greens and broccoli supply the body with vitamin K, which we require for blood clotting and bone growth; and broccoli provides potassium, a key element in maintaining a healthy blood pressure. These vegetables also contain glucosinolates, the compounds that give them their bitter taste when chopped, processed, or chewed; glucosinolates, in turn, contain isothiocyanates, which have been found to keep cancer cells from dividing and actively kill tumor cells in the bladder, breast, colon, liver, lung, and stomach of laboratory rats. Some vegetables in this family provide beta-carotene, which converts into the cognition-boosting vitamin A, while others have antioxidants including anthocyanins, agents that fight heart disease by promoting blood sugar metabolism and lowering cholesterol levels. Polyphenols, compounds that may lower blood sugar, soothe digestion, and increase brain function, are found in some cruciferous varieties. In addition, cruciferous vegetables provide plenty of fiber, a key factor in decreasing the risk of colorectal cancer, type 2 diabetes, and coronary artery disease.

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HISTORY Who was the first to determine that cruciferous vegetables are edible? The identity of this person has long since been lost to history, but we can guess that this discovery took place tens of thousands of years ago as the earliest humans sampled wild plants. The first vegetables to be grown domestically may have been cabbages, which appeared in the European countries more than three thousand years ago and in China a millennium before that. The Celts may have been the first to cultivate the leafy plants in Europe, while Egyptians did not begin to grow them until about 300 BC. The name of the brassica family comes from the Roman empire; the inclusion of the vegetable in the writings of Theophrastus, the recognized “father of botany,” tells us that cabbage had become a staple in the ancient cities. Cabbage also had medicinal properties, according to the Romans, who ate it before a night of heavy drinking to ease the effects of alcohol and who used the leaves to relieve gout and headaches. Cultivation of cabbage spread both eastward and westward from Europe, with the first round-headed cabbages showing up in the New World in the fifteenth century at the hands of French explorer Jacques Cartier. By this time, doctors on long ocean voyages used cabbage soaked in brine—a precursor to sauerkraut—as a poultice to treat sailors’ wounds and as a food staple to prevent scurvy. European explorers introduced cabbage to China and India, where the easy-to-grow crop quickly became a staple. Today China is the largest producer of cabbage in the world. Broccoli never grew wild in ancient fields. Cultivated by selective breeding of wild cabbage in the days of the Roman Empire, it originated in the Mediterranean region, where farmers selected the healthiest and tastiest plants from their cabbage crops and bred only those from one year to the next. Eventually, they achieved a plant with tight green flowers and a mild flavor, the ancestor to the broccoli we enjoy today. This process also produced cauliflower, kale, Brussels sprouts, and the attractive red and green cabbage heads preferred by shoppers. Traders and explorers brought these cultivated vegetables to the rest of Europe and to America in the 1700s.

THE CONTROVERSY While many foods get sporadic and often misplaced credit for fighting or even curing cancer, cruciferous vegetables actually contain glucosinolates and derivatives that result from digestion of these vegetables: sulforaphane and indole-3-carbinol, which have been shown to reduce the risk of bladder, breast, colorectal, endometrial, gastric, lung, ovarian, pancreatic, prostate, and renal cancer. In 2004, a report by the U.S. Department of Agriculture reviewed the epidemiological studies involving these vegetables and concluded that “consumption of cruciferous vegetables protects against cancer more effectively than the total intake of fruits and vegetables” (Keck and Finley). The report explained that this particular family of veggies can affect estrogen metabolism and decrease the activation of carcinogens in the body by inhibiting certain enzymes involved

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in tumor growth. Cruciferous vegetables also reduce inflammation in the body, making them an excellent choice for people with rheumatoid arthritis, asthma, ulcerative colitis, and other chronic conditions triggered by inflammation. The National Cancer Institute’s review of the many studies linking cruciferous vegetables with lowered cancer risk drew mixed conclusions, however. The institute acknowledges that one study does seem to draw a connection between women who ate more than five servings of these vegetables per week and a lower risk of lung cancer. Another indicates that women (but not men) who consumed a lot of cruciferous vegetables per week had a lower risk of colon cancer. One study compared men who had prostate cancer and men who did not and determined that men who ate more of these vegetables were less likely to have this cancer. Other studies in their review, however, did not deliver a close association between vegetable intake and cancer risk. The institute notes that studies show that these vegetables can have a positive effect on the biomarkers (DNA) of processes in the body that lead to cancer: In one study, indole-3-carbinol “was more effective than placebo” in inhibiting the growth of cancerous cells on the cervix. The American Institute for Cancer Research tells us that vitamins and minerals ingested by eating food are stronger cancer-fighting agents than supplements made in laboratories, but sales of supplements that claim to contain “cruciferous vegetable extract” or “activated broccoli seed extract” have reached all-time highs as consumers turn to mega-dose pills, many of which are frighteningly expensive. As is the case with many supplements, extracts of broccoli and others in this vegetable family may be much less effective than eating the plant itself, as glucosinolates have to go through the process of digestion to become absorbable in the gastrointestinal tract. In addition, labels on supplements usually do not identify the part of the plant from which the compound has been extracted; glucosinolates in the leaves and florets, for example, are different from those found in the stems and roots. Why not just eat more vegetables, instead of turning supplements into expensive urine? Some consumers may object to the production of intestinal gas that comes from eating these plants. In general, however, it seems that people will do just about anything to avoid having to eat broccoli, cauliflower, and kale, even though they are cheaper, more nourishing, and more effective solutions to fighting diseases than any packaged supplement. There is a flip side to this coin, however. Some studies have found that cruciferous vegetables may play a role in hypothyroidism, a condition in which the thyroid does not produce enough hormones. Eaten raw, these vegetables release compounds in the digestive system called goitrogens, which seem to interfere with the body’s ability to synthesize thyroid hormones. Some glucosinolates cause the release of thiocyanate ions, which fight iodine in the body and prevent the thyroid gland from functioning properly. This effect has only been produced in animals to date and only with consumption of very large amounts of cruciferous vegetables. In humans, this issue appears only in people who have an iodine deficiency; people who are otherwise healthy do not see an onset of hypothyroidism from eating these vegetables on a daily basis.

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With this in mind, the 2015–2020 Dietary Guidelines for Americans say that eating two and a half cups of vegetables daily from a variety of subgroups— from dark green, leafy vegetables to starchy ones and legumes—is a healthy choice within a 2,000-calorie-per-day diet. Among these, up to two and a half cups per week of dark green vegetables, including the cruciferous varieties, provides the desired health benefits with no real danger of upsetting a healthy thyroid. Recently, another issue has come to the surface, this one involving the mineral thallium. It began in 2012 with the work of Ernie Hubbard, a doctor and molecular biologist in Marin County, California, in which he discovered that a select group of his patients had high levels of thallium and cesium in their urine, eliminated through use of a “chelation” process (use of a formulated stimulant to release supposed toxins from the body). He discovered a study published in 2006 in which researchers planted kale, a “hyperaccumulator” of thallium, to draw the mineral from the ground where it had leached from a neighboring industrial site. Hubbard connected the dots and decided that the symptoms his patients showed—fatigue, arrhythmias, gluten sensitivity, mental “fogginess,” and hair loss—were all attributable to the amount of thallium they consumed through the large amounts of kale and cabbage they ate on a daily basis. Here are some of the issues other researchers have found with this theory. First, for kale to contain thallium (or other potentially toxic metal), it must grow in fields where there is thallium in the soil. This is not necessarily a common occurrence, despite the coverage this theory received in the mass media when Craftsmanship, an architectural magazine (not, notably, a peer-reviewed medical journal), broke the story in 2015. The media that picked up the story’s basic message—that kale may be bad for us because it draws dangerous metals right out of the ground and inserts them into our smoothies and salads—ran with it as if it were an FDA regulation. The fact is that Hubbard’s research took place largely in a lab he created for himself in his own kitchen, on the houseboat where he lives, on a carefully selected group of patients. He told the writer at Craftsmanship that when he instructed these patients to stop eating so much kale and to use a chelation solution to evacuate any metals in their bodies through their urine, the urine he tested revealed high concentrations of metals including thallium, cesium, nickel, lead, aluminum, and arsenic. He also sent kale samples to a lab and found that they, too, contained this range of metals. Whether the patients actually got these metals in their systems from kale and cabbage or from any number of other sources (Hubbard tested some jars of baby food and found the metals in there as well), Hubbard’s research could not determine for certain. Even the suggestion that kale might be unhealthy, however, set off a storm of media attention with headlines like “Eating Kale Is Making People Seriously Sick” (Delish.com), “Where Is All The Toxic Kale Coming From?” (HealthNewsReview), “Is Kale a Killer?” (DrWell.com), “Eating Too Much Kale May Result in Thallium Poisoning” (FirstWeFeast.com), and “Sorry, Foodies: We’re About to Ruin Kale,” from the normally more discerning Mother Jones.

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The fact is that no peer-reviewed journal has published any research on thallium levels in kale and their potential link to any kind of illness. Hubbard’s research never rose to the level of peer review. Thallium is a known toxin to humans, as reported by the Environmental Protection Agency, but the EPA’s 2009 report does not suggest that any specific food could carry enough thallium to cause a damaging level of toxicity. The research cited by the EPA does note that hair loss, neurological effects (fatigue, back pain, weakness, inability to walk, and mental effects), and kidney and liver damage all can be caused by thallium, as well as low birth weight in newborns whose mothers are exposed. None of this is associated in any scientific way with consumption of kale or any other cruciferous vegetable, however—the EPA’s analysis comes from studies involving rodents and high doses of thallium and related compounds or humans living within close proximity of an industrial site where thallium enters the air and the water supply. In short, there is no good science that indicates that kale is bad for humans because of its mineral content.

FURTHER READINGS “AICR’s Foods That Fight Cancer: Cruciferous Vegetables.” American Institute for Cancer Research. Accessed Sept. 5, 2019. https://www.aicr.org/foods-that-fight-cancer /broccoli-cruciferous.html Cook, Roberta. “Consumer Fresh Produce Demand Trends.” University of California, Davis, June 17, 2016. Accessed Sept. 4, 2019. https://arefiles.ucdavis.edu/uploads /filer_public/53/73/53730f77-1c54-4770-8792-3045e8bc74d2/shtcsecookconsumer 20160728.pdf “Cruciferous Vegetables and Cancer Prevention.” National Cancer Institute, June 7, 2012. Accessed Sept. 6, 2019. https://www.cancer.gov/about-cancer/causes-prevention/risk /diet/cruciferous-vegetables-fact-sheet#is-there-evidence-that-cruciferous-vegetables -can-help-reduce-cancer-risk-in-people Delarge, Barbara, et al. “Cruciferous Vegetables.” Linus Pauling Institute Micronutrient Information Center, Oregon State University, Dec. 2016. Accessed Sept. 6, 2019. https://lpi.oregonstate.edu/mic/food-beverages/cruciferous-vegetables Fenwick, G.R.; Heaney, R.K.; and Mullin, W.J. “Glucosinolates and Their Breakdown Products in Food and Food Plants.” Critical Review of Food Science and Nutrition, 1983;18(2), 123–201. Accessed Sept. 6, 2019. https://www.ncbi.nlm.nih.gov /pubmed/6337782 Fuentes, Francisco, et al. “Dietary Glucosinolates Sulforaphane, Phenethyl Isothiocyanate, Indole-3-Carbinol/3,3′-Diindolylmethane: Anti-oxidative Stress/Inflammation, Nrf2, Epigenetics/Epigenomics and In Vivo Cancer Chemopreventive Efficacy.” Current Pharmacology Reports, May 2015, 1(3), 179–196. Accessed Sept. 6, 2019. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4596548/ Hecht, S.S. “Inhibition of Carcinogenesis by Isothiocyanates.” Drug Metabolism Reviews, 2000, 32(3–4), 395–411. Accessed Sept. 5, 2019. https://www.ncbi.nlm.nih.gov /pubmed/11139137 Jiang, Y., et al. “Cruciferous Vegetable Intake Is Inversely Correlated with Circulating Levels of Proinflammatory Markers in Women.” Journal of the Academy of Nutrition and

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Dietetics, May 2014, 114(5), 700–708. Accessed Sept. 6, 2019. https://www.ncbi.nlm .nih.gov/pubmed/24630682 Johnson, I.T. “Glucosinolates: Bioavailability and Importance to Health.” International Journal of Vitamin and Nutrition Research, Jan. 2002, 72(1), 26–31. Accessed Sept. 5, 2019. https://www.ncbi.nlm.nih.gov/pubmed/11887749 Keck, A.S.; and Finley, J.W. “Cruciferous Vegetables: Cancer Protective Mechanisms of Glucosinolate Hydrolysis Products and Selenium.” Integrative Cancer Therapies, Mar. 2004, 3(1), 5–12. Accessed Sept. 6, 2019. https://www.ncbi.nlm.nih.gov /pubmed/15035868 Oppenheimer, Todd. “The Vegetable Detective.” Craftsmanship, summer 2015. Accessed Sept. 6, 2019. https://craftsmanship.net/the-vegetable-detective/ Orem, William. “The First Broccoli.” Moment of Science, Indiana Public Media, Dec. 29, 2016. Accessed Sept. 6, 2019. https://indianapublicmedia.org/amomentofscience /the-first-broccoli/ Parr, Broderick; Bond, Jennifer K.; and Minor, Travis. “Vegetables and Pulses Outlook: Production Declines and Widening Trade Gap Hinder Per Capita Availability.” U.S. Department of Agriculture, May 6, 2019. Accessed Sept. 4, 2019. https://www.ers.usda .gov/webdocs/publications/93033/vgs-362.pdf?v=1958.8 Shahbandeh, M. “Global Production of Vegetables in 2017, by Type (in Million Metric Tons).” Statista, Jan. 28, 2019. Accessed Sept. 4, 2019. https://www.statista.com /statistics/264065/global-production-of-vegetables-by-type/ “Toxicological Review of Thallium and Compounds, CAS No. 7440–28–0.” U.S. Environmental Protection Agency, Sept. 2009. Accessed Sept. 6, 2019. https://cfpub.epa .gov/ncea/iris/iris_documents/documents/toxreviews/1012tr.pdf “US Production of Fresh Vegetables Decreased in 2018.” Vegetable Growers News, May 22, 2019. Accessed Sept. 4, 2019. https://vegetablegrowersnews.com/news/u-s -production-of-fresh-vegetables-decreased-in-2018/ Villarreal-Garcia, Daniel; and Jacobo-Velazquez, Daniel. “Glucosinolates from Broccoli: Nutraceutical Properties and Their Purification.” Journal of Nutraceuticals and Food Science, Mar. 10, 2016. Accessed Sept. 6, 2019. http://nutraceuticals.imedpub.com/gluco sinolates-from-broccoli-nutraceutical-properties-and-their-purification.php?aid=8986

Dairy Products WHAT ARE THEY? Dairy products are foods produced using the milk of mammals. In the United States, these are primarily made from the milk of cows, goats, and sheep, but around the world they may contain milk from water buffaloes, reindeer, horses, camels, donkeys, and a number of others. Milk, cream, cheese, sour cream, cottage cheese, yogurt, ice cream, and butter are some of the most familiar examples of dairy products.

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CURRENT CONSUMPTION STATISTICS AND TRENDS Americans consumed roughly 653 pounds of dairy products per person in 2019, according to the U.S. Department of Agriculture (USDA) Economic Research Service. This includes 141 pounds of milk and other “fluid products” like buttermilk and eggnog, 40.4 pounds of cheeses, 22.4 pounds of ice cream and other frozen milk products, 13.4 pounds of yogurt, and 6.2 pounds of butter. It also encompasses thousands of products that contain dairy ingredients like whey protein, nonfat dry milk, milk protein isolate, sodium caseinate, and milk solids, from baked goods to processed meats. Annual consumption of dairy products trended upward throughout the 2010s, from 605 pounds per person in 2010 to 646 pounds in 2016, with a slight dip in 2013 as the increase in obesity-related diseases around the world made weightconscious consumers shy away from full-fat dairy products like butter, cheese, and ice cream. With the increase in dairy soft drinks and single-serving milk products; new dairy snacks like single-serving cottage cheese, cups of Icelandic yogurt, and individually wrapped cheddar squares; varietal products like kefir and kombucha; and more low-fat, nonfat, and protein-fortified choices than ever before, dairy has held onto its market share even as plant-based milk and related products grow their consumer base.

NUTRITIONAL INFORMATION Dairy products are rich sources of protein and essential amino acids, important nutrients in building and retaining muscle mass. Protein produces a satiated effect, helping people who are dieting feel full longer and crave fewer highcalorie, energy-producing sweets. These products serve as the body’s primary source of calcium, which is required for strong bones and teeth, as well as the vitamin D the body needs to maintain calcium and phosphorus levels. Consumption of dairy products helps the body guard against osteoporosis. Milk and other dairy products are particularly important to children’s diets, as they help with bone formation and growth and provide the strength required for muscle growth and development. Vitamin D, with which many dairy products are fortified, plays a key role in lowering blood pressure, making it a crucial nutrient for heart health. Potassium, vitamin A, riboflavin, vitamin B12, zinc, choline, magnesium, and selenium are all found in dairy products, and all play roles in the body’s overall functioning.

HISTORY Virtually every human child receives milk in one form or another within moments of being born, making it the most basic and prevalent food in human history. The transition away from the mother’s breast and to “artificial feeding,”

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using bottles to give babies milk from other mammals, began in earnest at the end of the seventeenth century, according to Mark Kurlansky, author of the book Milk! A 10,000 Year Food Fracas. The practice became controversial almost instantly, especially as the public had no understanding of the dangers of spoiled milk—which began to grow bacteria within minutes of leaving the animal. In a world before refrigeration or even the existence of iceboxes, milk became dangerous before it could be consumed or turned into butter or cheese. In cities in the nineteenth century, landowning residents kept their own cows to provide milk to their families, but as the demand grew, the first large dairy operations began to appear. Stables filled with cows sprang up next door to breweries, where the mash left over from beermaking became feed for many head of cattle. The resulting milk, however, did not have the richness and robust color and texture of the milk to which people had become accustomed, giving rise to “blue milk,” a watery substance lacking in fat. “Producers added annatto to improve its color and chalk to give it body,” Kurlansky wrote. “They also added water to increase the amount of milk they could sell, and covered up the dilution by adding more chalk.” When widespread cholera in New York City in the 1840s became a death sentence for as many as half the babies in Manhattan, activist Robert Milham Hartley believed that dairies might be playing a role in the spread of disease. He had seen hundreds of dairy stables where cows were kept in miserably unsanitary conditions, were fed “slush” grain devoid of nutrition, and were forced to produce milk even when they were sick and dying. Hartley saw the possibility that the doctored milk—which he dubbed “swill milk”—could have a hand in causing so many babies and children to die in New York, Boston, Philadelphia, and Cincinnati, so he wrote a book in 1842, An Historical, Scientific, and Practical Essay on Milk, as an Article of Human Sustenance: With a Consideration of the Effects Consequent Upon the Present Unnatural Methods of Producing It for the Supply of Large Cities, to alert the public to this connection. Another fifteen years would pass, however, before an official report by the Common Council of Brooklyn revealed what Hartley had suspected: Malnourishment and mistreatment of cows too horrific to share here did not provide the nutrition that babies and children needed—in fact, it could well contain diseases that could be passed through the milk to humans. Children by the thousands died of malnutrition, tuberculosis, and other illnesses, while dairy owners made large amounts of money. In 1862, scientist Louis Pasteur at the University at Lille in France discovered that beverages including beer, wine, and milk became spoiled because of the growth of microorganisms in the liquid. He determined that heating these beverages to a temperature between 60°C and 100°C (140–212°F) killed these bacteria, germs, and mold, making the drinks safe for human consumption. This became the process of pasteurization, but it did not find practical use until German scientist Robert Koch, studying anatomy at the University of Göttingen, discovered that tuberculosis was spread to children through the milk delivered to them by dairies. The dairy industry quickly moved to embrace Koch’s work, using

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the pasteurization process to render the milk safe. Koch went on to develop a way to test cows for tuberculosis; huge numbers of infected cows were removed from dairies, essentially ending the spread of the disease through milk. A single process did not solve everything that was wrong with milk production, however. Dairies sent delivery people out into neighborhoods on foot with a yoke across their shoulders, on which hung two large, open buckets of milk straight from the cows. All manner of trash could fall into these buckets as they moved from place to place, and did—leaves, twigs, dirt, and so on might be carried in the ladle that delivered milk from the pail to the consumer. Consumers had the option of coming to the dairies and receiving their milk more directly, but this also involved ladling milk out of open buckets. Not until the 1894 invention of the sealed, glass milk bottle by Dr. Henry G. Thatcher of Potsdam, New York, did the industry begin to move toward a more sanitary way of dispensing milk to local consumers. While scientists and the dairy industry sorted out the issues of milk sanitation and safety, inventor Gail Borden determined a way to condense milk in a vacuum pan so that it could be canned, preserved, and carried great distances without refrigeration. His creation of sweetened condensed milk in cans quickly found customers when it was introduced in 1856, and in 1861, it became an immediate hit with the Union Army as the Civil War began. Cheese became part of people’s daily diet before written recordkeeping began, perhaps some eight thousand years ago when some Mediterranean shepherd must have used a sheep’s stomach to carry and store milk. Rennet, an enzyme that occurs naturally in the animal’s stomach, would have curdled the milk and turned it into a basic form of cheese. Millennia later, in 4000 BC, Sumerian documents show people eating what could only be cheese, and remnants of some form of cheese have turned up in Egyptian pottery dating back to 2300 BC. Romans developed a process for mass production, learning to culture this substance, age it, give it color and a wide variety of flavors, wrap it in rind, and do many of the other things that dairies do today to create their signature cheeses. Yogurt, created by fermenting milk using bacteria known as yogurt cultures, is also one of civilization’s oldest human-made foods. It gained popularity in Europe and North America in the early 1900s when Russian biologist Ilya Mechnikov, working at the Institut Pasteur in Paris, France, suggested that this staple food of Bulgaria might have something to do with the remarkable longevity of the people there. He took the initiative to spread the word about yogurt throughout Europe, and in 1919, Isaac Carasso developed an industrial process for making yogurt at his business in Barcelona, Spain. He called the business Danone, which later became Dannon as it expanded into the United States. Armenian immigrants Sarkis and Rose Colombosian, living in Andover, Massachusetts, opened their own production facility and called it Colombo and Sons. They delivered their yogurt to homes throughout New England, but it was not until the 1950s that it received national attention as a health food. Looking for a way to expand its popularity to those who found it too sour, the Colombosians added “fruit on the

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bottom,” making yogurt more appetizing to the Western palate and turning it into a confection as well as a healthy option.

THE CONTROVERSY A great deal of research has explored the question of whether dairy products are good or bad for the human body, with widely differing results. Some critics begin their argument against dairy with the declaration that consuming milk as an adult is unnatural and unnecessary for good health. Humans are the only animal that consumes the milk of other animals, and we did not do so before agriculture made it possible for us to collect the milk of cattle and other beasts. Only babies should drink milk, critics say, and only from their own mother’s breasts. This theory is borne out by the fact that 75 percent of the world’s human population is lactose intolerant, unable to digest milk’s most central carbohydrate. This point of view seems logical on its surface, but regional populations in North America, Europe, and Australia seem to have adapted to thousands of years of dairy products in their diets and are well able to digest lactose. In addition, lactose-intolerant people can digest yogurt, which contains probiotic enzymes, as well as aged cheeses that contain no lactose, and some high-fat products like butter. Not all milk and other dairy products are equal, according to a study that breaks down their composition. In 2008, Helena Lindmark Månsson determined that milk “continuously undergoes changes depending on e.g. breeding, feeding strategies, management of the cow, lactation stage and season.” Other studies discovered that cows feeding on green grass produce milk with more omega-3 fatty acids and vitamin K2 than cows fed on hay and other feed crops. As omega-3 fatty acids help protect against cardiovascular disease and K2 supports bone health, choosing dairy products from grass-fed cows may be a healthier option than from cows fed on grain. However, low-fat and nonfat dairy products lose these nutrients—and to maintain the same creamy consistency and flavor as full-fat milk products, producers often add significant amounts of sugar. This essentially negates the benefits that these products provide. The question of dietary calcium and its role in bone health has been hotly contested over the last several decades. A case control study in Australia, published in 1994, suggested that people who drink milk in their twenties actually increase their risk of hip fracture after age sixty-five. Even the researchers seemed skeptical of their own results, however, as they noted in their report: “Some of the results of this study were unanticipated and may be due to chance or bias. If confirmed by other studies, these results would challenge some current approaches to hip fracture prevention.” A study published in 1997 asked more than 77,000 women to fill out questionnaires in 1980, 1984, and 1986 about their daily dietary intake, as well as about

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fractures of the thighbone and wrist. The study determined that drinking two or more glasses of milk per day had no more effect on whether these women had a fracture than if they drank one glass or less of milk per week. This was an observational study, however, not one in which milk consumption was actually tested against a control group that did not drink milk, so fractures cannot be considered solely the cause-and-effect results of drinking or not drinking milk. A string of studies throughout the 1990s produced the opposite result, showing significantly positive effects of drinking milk on bone density in prepubescent girls and both premenopausal and postmenopausal women, while a 2013 study of 3,301 postmenopausal women referred for DEXA bone density screening found that women who reported the lowest dairy intake had the highest incidence of osteoporosis. In 2016, a paper published in the French journal Revue du Rhumatisme completed a literature review of all the studies to date. The team concluded that the studies that asked participants to recall their dietary habits over long periods of time or, in the Australian study’s case, as much as fifty years after the fact, could not be seen as valid. “Reliable dietary intake data must be collected over prolonged periods, often long before the occurrence of a fracture, and defective recall may therefore introduce a major yet often unrecognized bias, particularly in populations where calcium deficiency is uncommon,” they wrote. “To date, there is no conclusive evidence that we should modify our currently high level of consumption of cow’s milk.” What about dairy fat and its effect on obesity and diabetes? Many dairy products contain saturated fat. Studies have shown that the saturated fat in butter is more likely to produce LDL cholesterol in the body than the saturated fat in cheese. A meta-analysis of randomized controlled trials, published in Nutrition Review in 2015, showed that butter caused larger concentrations of LDL cholesterol than cheese did. However, an extensive integration of data from 16 studies, published in the European Journal of Nutrition in 2013, determined that consumption of high-fat dairy products actually reduced the risk of obesity and heart disease. “Studies examining the relationship between high-fat dairy consumption and metabolic health reported either an inverse or no association,” the authors said. “Studies investigating the connection between high-fat dairy intake and diabetes or cardiovascular disease incidence were inconsistent.” Science struggles with the question of whether or not dairy products are linked to heart disease. Studies work in one of two directions: examining subjects who have already had a heart attack or stroke, working backwards to determine their consumption of dairy products; or attempting to predict a population’s risk of heart attack based on how much dairy they eat and drink. Studies also must control for additional risk factors that are known to lead to heart attacks and stroke, including other dietary choices, smoking, and alcohol and drug use. A study in 2007 looked at dairy fat intake to see if it increased the risk of heart disease, using data from 32,826 subjects in the Nurses’ Health Study. Researchers

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used data from the 166 subjects who actually developed heart disease between the study’s launch in 1989 and additional testing in 1996, matching them with 327 control subjects. The team looked for biomarkers of dairy fat intake in the blood of the subjects who had developed heart disease and found high concentrations of these biomarkers. Their conclusion: The biomarkers indicated that “a high intake of dairy fat is associated with a greater risk of [ischemic heart disease].” An association is not necessarily a causal relationship, however. Other studies have examined the link between drinking milk and heart disease and found the cause-and-effect relationship to be tenuous. A 2004 literature review of cohort studies that featured an estimate of milk and other dairy consumption and vascular disease “provided no convincing evidence that milk is harmful. . . . The studies, taken together, suggest that milk drinking may be associated with a small but worthwhile reduction in heart disease and stroke risk.” A 2010 study involving nearly 4,000 subjects in Costa Rica tested the theory that conjugated linoleic acid (CLA), produced in grass-fed cows’ digestive and rumination process, “might offset the adverse effect of the saturated fat content of dairy products.” Indeed, the subjects who drank this milk had a lower incidence of heart attacks than those who did not. Many other meta-analyses of other studies, biomarker studies, and more have attempted to examine specific saturated fats found in dairy products and their effect on heart disease and stroke, but for the most part, their results have been speculative. In short, high-fat dairy products may actually be better for metabolic health than their low-fat and fat-free counterparts—or, as several studies indicate, they may have no effect on heart disease, diabetes, and obesity at all. None of this has changed the American Heart Association’s recommendations on dairy products for heart health, however. The AHA continues to advise no more than two to three servings of fat-free or low-fat dairy products daily for the adult diet and four servings for teenagers and older adults.

FURTHER READINGS Cumming, R.G.; and Klineberg, R.J. “Case-Control Study of Risk Factors for Hip Fractures in the Elderly.” American Journal of Epidemiology, Mar. 1, 1994, 139(5), 493–503. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pubmed/8154473 “Dairy Products: Per Capita Consumption, United States (Annual).” Dairy Data, U.S. Department of Agriculture Economic Research Service, Sept. 4, 2020. Accessed Apr.13, 2021. https://www.ers.usda.gov/data-products/dairy-data/ de Goede, J.; Geleijnse, J.M.; Ding, E.L.; and Soedamah-Muthu, S.S. “Effect of Cheese Consumption on Blood Lipids: A Systematic Review and Meta-analysis of Randomized Controlled Trials.” Nutrition Reviews, 2015, 73(5), 259–275. https://academic.oup.com /nutritionreviews/article/73/5/259/186239 de Vrese, M., et al. “Probiotics—Compensation for Lactase Insufficiency.” American Journal of Clinical Nutrition, Feb. 2001, 72(2 supplemental), 421S–429S. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pubmed/11157352

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Elwood, P.C., et al. “Milk Drinking, Ischaemic Heart Disease and Ischaemic Stroke II. Evidence from Cohort Studies.” European Journal of Clinical Nutrition, Apr. 24, 2004, 58, 718–724. Accessed Jan. 20, 2020. https://www.nature.com/articles/1601869 Fardellone, Patrice, et al. “Osteoporosis: Is Milk a Kindness or a Curse?” Revue du Rhumatisme, Oct. 2016, 83(5), 334–340. Accessed Jan. 19, 2020. https://www.sciencedirect .com/science/article/pii/S1297319X16301178?via%3Dihub Feskanich, D., et al. “Milk, Dietary Calcium, and Bone Fractures in Women: A 12-Year Prospective Study.” American Journal of Public Health, June 1997, 87(6), 992–997. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pubmed/9224182 Gunnars, Kris. “Milk and Osteoporosis—Is Dairy Really Good for Your Bones?” Healthline, Apr. 20, 2018. Accessed Jan. 19, 2020. https://www.healthline.com/nutrition /is-dairy-good-for-your-bones#section1 Gunnars, Kris. “Is Dairy Bad for You, or Good? The Milky, Cheesy Truth.” Healthline, Nov. 15, 2018. Accessed Jan. 19, 2020. https://www.healthline.com/nutrition /is-dairy-bad-or-good Hebeisen, D.F., et al. “Increased Concentrations of Omega-3 Fatty Acids in Milk and Platelet Rich Plasma of Grass-Fed Cows.” International Journal of Vitamin and Nutrition Research, 1993, 63(3), 229–233. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih .gov/pubmed/7905466 Kratz, Mario, et al. “The Relationship Between High-Fat Dairy Consumption and Obesity, Cardiovascular, and Metabolic Disease.” European Journal of Nutrition, Feb. 2013, 52(1), 1–24. Accessed Jan. 19, 2020. https://link.springer.com/article/10.1007 %2Fs00394-012-0418-1 Kurlansky, Mark. Milk! A 10,000 Year Food Fracas. New York: Bloomsbury Publishing, 2019. Månsson, Helena Lindmark. “Fatty Acids in Bovine Milk Fat.” Food & Nutrition Research, 2008, 52(10). Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles /PMC2596709/ “Nutrients and Health Benefits.” ChooseMyPlate, U.S. Department of Agriculture. Accessed Jan. 18, 2020. https://www.choosemyplate.gov/eathealthy/dairy/dairy -nutrients-health Smit, L.A.; Baylin, A.; and Campos, H. “Conjugated Linoleic Acid in Adipose Tissues and Risk of Myocardial Infarction.” American Journal of Clinical Nutrition, July 2010, 92(1), 34–40. Accessed Jan. 20, 2020. https://www.ncbi.nlm.nih.gov/pubmed/204 63040 Soerensen, K.V.; Thorning, T.K.; Astrup, A.; Kristensen, M.; and Lorenzen, J.K. “Effect of Dairy Calcium from Cheese and Milk on Fecal Fat Excretion, Blood Lipids, and Appetite in Young Men.” American Journal of Clinical Nutrition, 2014, 95(5), 984–991. https://academic.oup.com/ajcn/article/99/5/984/4577518 Sun, Q.; Ma, J.; Campos, H.; and Hu, F.B. “Plasma and Erythrocyte Biomarkers of Dairy Fat Intake and Risk of Ischemic Heart Disease.” American Journal of Clinical Nutrition, Oct. 2007, 86(4), 929–937. Accessed Jan. 20, 2020. https://www.ncbi.nlm.nih.gov /pubmed/17921367 Tholstrup, T.; Hoy, C.E.; Andersen, L.N.; Christensen, R.D.; and Sandstrom, B. “Does Fat in Milk, Butter and Cheese Affect Blood Lipids and Cholesterol Differently?” Journal of the American College of Nutrition, 2004, 23(2), 169–176. https://www.tandfonline.com /doi/abs/10.1080/07315724.2004.10719358

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Thorning, Tanja Kongerslev, et al. “Milk and Dairy Products: Good or Bad for Human Health? An Assessment of the Totality of Scientific Evidence.” Food & Nutrition Research, 2016, 60(10). Accessed Jan. 18, 2020. https://www.ncbi.nlm.nih.gov/pmc /articles/PMC5122229/ Varenna, M., et al. “The Association Between Osteoporosis and Hypertension: The Role of a Low Dairy Intake.” Calcified Tissue International, July 2013, 93(1), 86–92. Accessed Jan. 19, 2020. https://www.ncbi.nlm.nih.gov/pubmed/23652773

Eggs WHAT ARE THEY? The reproduction method for birds, reptiles, amphibians, insects, arachnids, crustaceans, fish, mollusks, and some mammals, eggs have served as food for human beings for thousands of years, since well before recorded history. Nearly all eggs available to U.S. consumers come from chickens, though eggs from other birds are sometimes offered as delicacies. Other cultures may have access to eggs from gulls, guineafowl, ostriches, pheasants, and other birds. Fish eggs (roe or caviar) can be found in many grocery stores and specialty shops. This book focuses on chicken eggs.

CURRENT CONSUMPTION STATISTICS AND TRENDS United Egg Producers (UEP) reports that 265 million cases of eggs (with thirty dozen eggs per case, for a total of 95.4 billion eggs) were produced in 2018, with 157.6 million cases sold in retail stores and another 90.1 million cases sold to food manufacturers and processors. Another 19.6 million cases went to food service companies. In the United States, people consume roughly 279 eggs per year, including eggs as ingredients in packaged products. This figure has climbed significantly since 2000, in part because the productivity of laying hens has increased through “improved health and disease prevention, nutrition, genetics, and flock management,” according to UEP. The removal of cholesterol limits in the 2015–2020 Dietary Guidelines for Americans returned eggs to kitchens across the United States, increasing demand from 256.3 per capita in 2015 to 279 in 2019.

NUTRITIONAL INFORMATION One large chicken egg contains 6 g of protein, as well as significant amounts of riboflavin, vitamin A, niacin, vitamin B12, biotin, vitamin D, iron, pantothenic acid, phosphorus, iodine, zinc, selenium, choline, and antioxidants lutein and

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zeaxanthin, which have health benefits for vision. It also contains cholesterol and 1.5 g of saturated fat.

HISTORY Eggs long predated humans, and the date on which they became a human food source cannot possibly be known, but records from ancient Egypt and China both make note of domesticated birds laying eggs for human consumption as far back as 1400 BC. Europe adopted the practice as early as 600 BC, while Christopher Columbus brought chickens on his second voyage to the New World in 1493. Before the twentieth century, most families either kept their own chickens or purchased eggs directly from private farmers. This began to change in the 1920s, as farmers saw profit in selling eggs and began to increase their own flocks to provide eggs for their neighborhoods or at farmers’ markets in nearby towns and cities. Large numbers of chickens living in close quarters began to pose issues for farmers, however, as hens naturally established a pecking order—hence the name—and the larger and stronger birds gobbled up most of the food farmers provided. Chicken hatcheries became early adopters of selective breeding, choosing the healthiest hens to produce chicks that would become the next generation of layers. Chickens lived outdoors for the most part, a situation that resulted in losses to predators and weather. Keeping chicken pens clean and protecting the birds from parasites also became significant problems for farmers, so when research on indoor hen houses demonstrated that the cost of the houses would be recouped in dramatically reduced losses of birds, farmers moved to these specialized quarters in droves. “Indoor houses . . . helped to prevent parasite infestations and reduce the spread of diseases from outside carriers, including rodents and even humans,” the American Egg Board explains in a concise history of commercial egg production. “Instead of hens eating whatever they found outside, feed could be better controlled indoors, too.” By the 1940s, most hen houses supplied wire housing for each bird, moving them off the floor and making it easier for each hen to get the nutrition she needed, rather than battling other hens for her share of the feed. Farmers found it easier to keep the houses clean with the birds living in cages. Healthier hens laid more eggs, so the houses soon required conveyor belts to collect the eggs and move them to the egg washing system. Egg producing facilities grew exponentially under these conditions, until they reached the size they are today, with as many as one million birds in a single flock and more than 280 million hens across the United States. Meanwhile, nutrition scientists had begun to explore the link between blood lipids and heart health and had discovered a causal relationship between high cholesterol and heart disease. Most common knowledge in the scientific community in the first half of the twentieth century indicated that rising cholesterol levels were simply a fact of aging, so the possibility that food choices and eating patterns might cause high cholesterol had not been considered by most

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researchers. This changed in 1955 when Ancel Keys at the University of Minnesota suggested: There is an important relationship between the concentration of certain lipid fractions in the blood and the development of atherosclerosis and the coronary heart disease it produces. The outstanding characteristic of atherosclerosis is the presence of lipid deposits, mainly cholesterol, in the walls of the arteries. And both in man and animals the most obvious factor that affects the blood lipids is the diet.

Studies began to explore this connection, and as the research produced a correlation between cholesterol and heart disease, the American Heart Association took the bold step in 1968 of recommending that people consume no more than 300 mg of cholesterol in their diet per day and no more than three whole eggs per week. In 1973, researchers began the landmark Coronary Primary Prevention Trial (CPPT), a sixteen-year randomized double-blind trial that tested the effectiveness of reducing the risk of CHD by lowering cholesterol. The study showed that lowering LDL levels in men could reduce the incidence of mortality from heart disease, providing “strong evidence for a causal role for these lipids in the pathogenesis of CHD.” This opened the door to the development of cholesterollowering pharmaceuticals, but it would take decades before the egg found its way back to American dining tables.

THE CONTROVERSY Once the American Heart Association labeled the egg yolk as the highest cholesterol food in most people’s diets in 1968, the egg industry began to see a marked decline in sales. After the CPPT published findings that a pharmaceutical solution to high cholesterol could help guard against heart disease, the egg had a chance for a comeback—but on March 26, 1984, Time magazine published a cover photo of a dinner-plate face, with a frowning bacon-strip mouth and two fried eggs for eyes. The headline: “Cholesterol: And Now for The Bad News.” The industry had several options: It could accept its fate and begin to downsize to keep pace with the dwindling demand or it could fight back—but any effort to discredit the cholesterol findings could be seen as putting its own profits before the health of its customers. If it chose to fund its own research, however, the results would be seen as nothing more than a special interest group trying to rationalize or even negate highly credible and legitimate science—science, in fact, that had resulted in a 1985 Nobel Prize for its lead researchers. As bad press for the egg mounted—with the Select Committee on Nutrition, the National Cholesterol Education Program of the Heart, Lung, and Blood Institute, and a wide range of nongovernment organizations piling on—the egg industry responded. First, it produced an egg substitute product: Egg Beaters, which contains egg whites and added thickeners (see guar gum and xanthan gum in this

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book), but leaves out the high-cholesterol egg yolk. Egg Beaters was introduced in 1972 and continues to be a popular product with people working to lower their LDL levels. Its success soon generated a number of similar products, including many flavored varieties and egg whites in pourable form. In 1984, the egg industry created the Egg Nutrition Center (ENC). The ENC operated separately from the commercial side of egg production, forming its own advisory panel of university-based scientists to put together a long-range research plan. Rather than attempt to disprove the many dietary guidelines that limited eggs, the ENC’s researchers began by focusing on eggs as a low-cost, nutrient-rich protein source, as well as on their role in aiding people in maintaining a healthy weight. Results of studies emphasized the role of eggs in helping elderly consumers preserve muscle tissue mass and the importance of antioxidants lutein and zeaxanthin, supplied by eggs in abundance, in combatting cataracts and macular degeneration. Research determined that eggs contain choline, an essential nutrient for fetal and neonatal brain development, that is often lacking in pregnant women’s diet. More recently, studies funded by the ENC, as well as by the Centers for Disease Control and Prevention or the National Institutes of Health, began to generate good news for egg producers. A cohort review published in 2007 looked at 9,734 adults aged twenty-five to seventy-four to find a link between egg consumption and cardiovascular disease. Researchers categorized egg consumption into groups: those who ate less than one egg per week, those who ate one to six eggs, and a final group who ate more than six eggs weekly. The report concluded: After adjusting for differences in age, gender, race, serum cholesterol level, body mass index, diabetes mellitus, systolic blood pressure, educational status and cigarette smoking, no significant difference was observed between persons who consumed greater than 6 eggs per week compared to those who consume none or less than 1 egg per week in regards to any stroke . . . or coronary artery disease. Consumption of greater than six eggs per week (average of one egg or greater per day) does not increase the risk of stroke and ischemic stroke.

In 2010, Valentine Njike et al. completed a randomized, placebo-controlled crossover trial of forty adults with high cholesterol. The subjects first ate a single “dose” of three hardboiled eggs or a sausage and cheese breakfast sandwich and then tested the function of the endothelium—the lining of blood vessels, a wellknown factor in heart disease. Neither high-cholesterol meal had any effect on endothelial function. Next, the subjects ate either a half-cup of cooked Egg Beaters or two eggs daily for six weeks and found that eating eggs had no effect on cholesterol levels. Eating Egg Beaters, however, did indeed lower the subjects’ cholesterol. In 2015, in a randomized, controlled crossover trial of thirty-two adults with diagnosed cardiovascular disease, Katz et al. tested three different breakfast options: a meal with two eggs, a meal with half a cup of cooked Egg Beaters, and a high carbohydrate breakfast with no eggs. The subjects ate the assigned breakfast

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daily for six weeks and found that eating two eggs daily had no effect on blood pressure, cholesterol, or body weight. “No outcomes differed (P >.05) between eggs and Egg Beaters,” the study concluded. One of the most recent cohort studies took place in China, recruiting more than 500,000 adults from ten different regions and following them for nine years. Researchers surveyed the health and eating habits of this enormous base of participants and found that “daily egg consumption was associated with a lower risk of [cardiovascular disease]. . . . Among Chinese adults, a moderate level of egg consumption (up to